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A MANUAL 



OF 



PHYSICAL DIAGl^OSIS 



BY 

AUSTIN :^LINT, M.D., LL.D. 

LATE PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE AND OF 
CLINICAL MEDICINE IN BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC. 



SEVENTH EDITION, REVISED BY 

HENRY C. THACHER, M.S., M.D. 

ASSOCIATE IN MEDICINE IN THE COLLEGE OF PHYSICIANS AND SURGEONS OF 

COLUMBIA university; ASSISTANT ATTENDING PHYSICIAN, 

ROOSEVELT AND LINCOLN HOSPITALS, NEW YORK 



ILLUSTRATED 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1917 



I^t^"' 



f^^A 



C\ 



\ 



Entered according to the Act of Congress, in the year 1917, by 

LEA & FEBIGER, 
in the Office of the Librarian of Congress. All rights reserved. 



FEB -3 1917 



J^ 



/P ^ 2^^ ©CI.A453915 



PREFACE TO THE SEVEI^TH EDITION. 



Recent advancements in the laboratory side of 
diagnosis have discouraged the acquisition of that 
thoroughness and skill in the employment of simpler 
methods which were so essential to the earlier masters 
of clinical medicine. Even among instructors the dis- 
position to subject every difficulty in diagnosis to the 
a:-ray, polygraph, electrocardiograph, etc., before the 
older means of examination have been exhausted, is 
daily developing. This tendency to adopt the dramatic, 
and slight the direct use of his unaided senses, doubly 
appeals to the student, for he naturally fails to foresee 
how often in practice he will lack the advantages of 
such apparatus. 

The particular need which this manual was intended 
to fill, and which it is expected that it will again fill, is 
the demand of the student and of many graduates in 
medicine, for simplicity, directness, exactness, and skill 
in dealing with physical signs in health and diseases. 

In preparing the present edition it has been the 
purpose of the Editor to retain, and as far as possible 
to augment, by his additions and modifications, those 
features which have heretofore so strongly appealed to 
the student and the general reader. To this end a 



iv PREFACE 

chapter on the Physics related to the subject has been 
introduced. It is hoped that it will assist the student to 
correlate the phenomena of auscultation and percussion 
with the principles he learned during his academic 
courses. Certain minor methods of examination, as 
Inspection, Palpation, etc., have been brought into 
greater prominence than the distinguished Author 
originally accorded them. / 

Our knowledge in ^no phase of internal medicine has 
progressed more rapidly during recent years than in 
Cardiac Disorders. Hence, special effort has been 
exerted to bring the chapters devoted to examination 
of the Heart into accord with modern ideas. The sub- 
ject of Arrhythmia has been rewritten and its usual 
types diagrammatically presented. On page 297 a 
diagram has been introduced which should enable and 
encourage the student to visualize the auscultatory 
signs of cardiac disease. 

Finally, the Editor would allude to the satisfaction 
he has felt in associating his name w^ith a work that 
bears the vital impress of Professor Flint's genius. 

Henry C. Thacher. 
New York, 1917. 



CONTENTS. 



CHAPTER I. 

The Physical Basis of Auscultation and Percussion 

OF THE Lungs 17 

CHAPTER II. 

Anatomical, Physiological and Pathological Prin- 
ciples Involved in Percussion and Auscultation 40 

CHAPTER III. 
Percussion in Health 71 

CHAPTER IV. 
Percussion in Disease 93 

CHAPTER V. 
Auscultation in Health 107 

CHAPTER VI. 

Auscultation in Disease 130 



vi CONTENTS 



CHAPTER VII. 

The Physical Diagnosis of Diseases of the Respi- 
ratory Organs 190 



CHAPTER VIII. 

The Physical Conditions of the Heart in Health 
AND Disease. The Heart Sounds and Cardiac 
Murmurs 251 



CHAPTER IX. 

The Physical Diagnosis of Diseases of the Heart 

and of Thoracic Aneurism . 321 



CHAPTER X. 
Examination of the Abdomen . 356 

CHAPTER XI. 
Order of Physical Examination 367 



PHYSICAL DIAGNOSIS. 



CHAPTER I. 

THE PHYSICAL BASIS OF AUSCULTATION 
AND PERCUSSION OF THE LUNGS. 

Physics of sound — Simple sounds or tones — Intensity — Pitch — 
Noises — Quahty or timbre — Action of resonators — ^Transmission 
of sounds— Percussion of bones — Soft tissues — ^Tissues contain- 
ing large collections of air — Open and closed cavities — Tissues 
containing air in minute subdivisions — Auscultation — Transmis- 
sion of sounds from bronchi through solid lung — Through 
alveolar tissue — Breath sounds over normal lung — Solid tumors 
— Pulmonary cavities and pneumothorax — Pleural effusions — ■ 
Adventitious sounds — Moist rales — Modification due to condi- 
tion of parenchyma — Consonating rales — Dry rales — Crepitant 
rales — Pleural friction and pleural splashing sounds. 

PHYSICAL BASIS OF PERCUSSION AND 
AUSCULTATION. 

The more important methods of physical examination 
of the lungs depend upon alterations of the sounds 
elicited by striking upon the chest wall (percussion) 
and upon alterations of the sounds normally heard 
at the chest wall when the patient breathes, speaks or 
2 



18 PHYSICAL BASIS OF AUSCULTATION 

whispers (auscultation). It may be worth our while, 
therefore, to sketch briefly the characteristics of 
sounds in general, and also to give particular atten- 
tion in the main principles governing and modifying 
sounds under similar conditions than those met with 
in the thorax. 

PHYSICS OF SOUND. 

Sound is a sensation produced when vibrations 
reach and stimulate the ear. The human organ of 
hearing is sensitive to vibrations occurring at a rate 
of between 16 and 40,000 per second, provided they 
be transmitted to it with reasonable intensity. When- 
ever we set up vibration in a tuning-fork, drum, 
string, vocal cord, or what you will, these are propa- 
gated by the surrounding air in the form of rapidly 
alternating waves of condensation and rarefaction, 
which * radiate away with great velocity — in air at a 
rate of 11,000 to 12,000 feet per second. Should the 
sounding body be in contact with a solid elastic sub- 
stance, the sound waves may be transmitted even 
better by the solid than by the air, as along the railroad 
tracks or iron water-pipes. The ability of solids to 
transmit sound waves varies Avith the mass and elas- 
ticity — the latter meaning their ability to resume 
their original form, when that force which altered 
that form ceases to act. Sound waves may also pass 
with varying loss of intensity from air to solid, and 
solid to air again — for example, through the walls 
from one closed room to another. The quality of the 



PHYSICS OF SOUND 19 

transmitting substance and the distance are as important 
in determining the sounds we hear as the intensity of 
the original vibrations. 

As the pendulum is the simplest form of a slowly 
oscillating body, so an elastic rod fixed at one end and 
free at the other gives us the least complicated rapid 
vibrator. When two such rods of equal proportions 
are fixed side by side on a common base, as by clamp- 
ing in a hand vise, their oscillations strengthen one 
another, so that they continue much longer in motion, 
and are therefore best suited for the production and 
analysis of simple sounds of a fixed uniform wave 
length. Such a pair of parallel rods constitutes a 
tuning-fork. The sound produced by them, when 
their regular rapid oscillation is transmitting its uni- 
form series of waves to the ear, is called a tone. Tones 
are sounds of definite uniform wave length. 

Intensity of Sound. — ^\^^hen we examine such a tuning- 
fork we find that, like a pendulum of given length, 
its oscillations may vary greatly in size, depending 
upon the force with which it is set in motion, but the 
number per minute is an inherent fixed character- 
istic of the individual instrument; and with one or 
one hundred tuning-forks of the same elasticity, mass 
and proportions, tones can be produced which may 
differ in quantity, but in that alone. Such differences 
in quantity or intensity depend merely upon the violence 
with which the sound waves reach the ear, and may be 
brought about on the one hand by altering the force 
with which the tuning-fork is set in motion; and on 



20 PHYSICAL BASIS OF AUSCULTATION 

the other hand by varying the distance of the ear 
from the instrument, or the character of the trans- 
mitting medium. The intensity of a sound is simply 
the loudness with which it is heard. 

Pitch. — ^With tuning-forks of different sizes the 
tones produced, even though they be equally loud or 
intense, are not alike, but differ in another attribute 
called pitch. We find that the smaller the forks, 
the more rapid the vibrations and the higher the pitch, 
no matter whether the intensity of the tones be great 
or small. Pitch depends upon the rate with which 
vibrations of definite periodicity or rhythm reach the 
ear, and is a characteristic of every such rhythmical 
sound or tone. 

Noises. — ^When several or many tones of unrelated 
wave length are simultaneously produced, the result- 
ing sound waves are irregular vibrations without 
periodicity or rhythm. Such non-musical sounds have 
no definite pitch and are called noises. Although 
noises have, strictly speaking, no true pitch, in physical 
diagnosis we are constantly comparing them in regard 
to this quality. In so doing we are really referring 
to the pitch of the predominating or of the lowest tone 
present in these compound sounds. 

Quality or Timbre. — Sound waves of equal rate and 
intensity can be produced from a great number of 
vibrating bodies and yet even then they are not 
entirely alike. This is due to differences in what is 
called quality (or timbre) which are so great that the 
same notes produced on different instruments are 



PHYSICS OF SOUND 



21 



readily distinguished by even the most untrained 
ear. These striking, though indefinable, differences 
in quality (or timbre) depend upon the fact that our 
sonorous bodies do not confine themselves to the 
production of their single fundamental tone, but 




Fig. 1. — Vibration waves of a 
simple tone (tuning-fork). 



Fig. 2. — Vibration waves of 
intense fundamental tone with 
faint overtones (violin). 




Fig. 3. — A complete musical 
instrument. 



Fig. 4. — Human voice. 



Vibration waves in which the overtones are intensified, giving a 
very distinct individuality to the sound. 

Figs. 1-4. — Diagram of musical sound waves composed of a simple 
tone and of fundamental plus overtones. 



add to this secondary regular tones, two, three, 
four, etc., times the rate of the fundamental. The 
violin string thus vibrates not merely as a whole but 
also in parts of one-half, one-third, one-fourth, etc., 
and the sound produced consists of not only the 
fundamental but also the superimposed overtones. It 



22 PHYSICAL BASIS OF AUSCULTATION 

is the latter that give quahty to sounds; and it is on 
their faculty of producing overtones that musical 
instruments depend for their individuality. 

Resonators. — Overtones and fundamental tones are 
magnified by the presence of a sonorous body or 
resonator whose wall or air-content takes up and 
vibrates in unison with the original tones, adding 
greatly to their intensity and quality. The resonator, 
according to its ability to intensify these overtones, is 
indeed far more important in contributing quality 
than is the vibrator itself. This is perhaps best 
emphasized in the case of violin bodies which vary so 
extraordinarily in value, although their strings are so 
insignificant in cost. Overtones accompany the fun- 
damental tone of most musical sounds. 

In the construction of sounding boxes or resonators 
for musical instruments the maker's skill is directed 
to producing a sounding body that will covibrate with 
sounds of many degrees of pitch. All elastic struc- 
ture, however, have their own vibration times, and when 
oscillations are transmitted to them at that rate 
they are set in motion. This is daily seen in the 
laboratory when, as an ill-balanced centrifuge is 
gradually increased in speed, now one, and now 
another pipette rack, beaker or burette begins to rattle, 
and subsides only when the centrifuge's vibrations 
have altered to become more or less rapid. It is this 
which makes it necessary that marching troops break 
step while crossing bridges, and upon this same funda- 
mental law depends the fact that, if the sound waves 



PHYSICS OF SOUND 23 

of one tuning-fork reach a fork, string or ball or other 
sonorous body of similar pitch, the latter is set in 
action. This law is made of practical use in analyzing 
sounds composed of several tones by exposing a series 
of resonators to the compound vibration, and noting 
which resonators are set in co vibration. It is also of 
great importance in the construction of stethoscope 
bells. When dealing with faint murmurs of low 
pitch, the old Gannet type of stethoscope not infre- 
quently settled an argument; because the large reso- 
nating cavity of its bell intensified murmurs of that 
pitch. On the other hand, soft murmurs of aortic 
insufficiency are notorious for occasionally being far 
better heard by the direct ear than with the popular 
small-bell stethoscopes. While the complex reso- 
nators of musical instruments strengthen sounds of 
many degrees of pitch, the simpler resonating body 
strengthens a limited set of sound vibrations. 

The Transmission of Sounds. — This demands the 
presence of an elastic medium between the point of 
production and the ear. In ordinary daily life the 
tendency of the waves to be transmitted in a straight 
line and the distance are the more essential factors in 
modifying the intensity with which they are heard. 
In physical diagnoses, however, we are chiefly interested 
in the quality of the intervening substance, for it is 
chiefly to determine abnormal physical conditions of 
this substance that we listen to the sounds at all. 
Transmission through any uniform medium varies with 
the elasticity coefficient, mass, and density of the 



24 PHYSICAL BASIS OF AUSCULTATION 

individual substance, and in the body we may simply 
note that bones transmit well and that soft tissues 
transmit poorly, though do somewhat better if com- 
pressed, as when the stethoscope bell is applied with 
considerable force. Where the intervening substance 
is not uniform, however, a most important though 
less obvious factor enters — dispersion. Sound waves, 
like the waves of light, radiate in straight lines, 
decrease in intensity with the square of the distance 
and traverse certain substances better than others. 
This similarity is further emphasized by the fact that 
sound waves may be projected to a given spot when 
the point of production is at the focus of a parabolic 
resonator, and that they may be concentrated and 
focussed by properly constructed lenses of hydrogen. 
In such experiments the facility with which waves 
enter or are reflected back from the surface of the 
second medium depends on the quality of the said 
medium, and the angle of its surface. And just as 
a ray of light may be more diminished by passing 
it through a little ground glass than through many 
times as thick a layer of clear glass, so sounds 
that would be readily transmitted a considerable dis- 
tance in wood are stopped by a thin layer of sawdust. 
The lack of penetration in each case depends upon 
the fact that with each change of transmission medium 
some of the waves are reflected backward or diverted 
laterally, and the intensity suffers accordingly. To 
limit the intensity of light the absorbing power of 
colors is so much more practical that the method of 



PHYSICS OF PERCUSSION 25 

dispersion, as in the use of ground glass, is seldom 
employed. In the ease of sound, however, dispersion 
is constantly employed, and underlies the use of car- 
pets, padded walls, felt partition, and the like. 

PHYSICS OF PERCUSSION. 

With these more important laws of physics in 
mind, we turn now to see how they may explain the 
sounds obtained by auscultation and percussion. 

• Percussion consists in tapping upon the chest wall 
and noting the sounds produced. If we strike any 
series of miscellaneous objects the sounds evoked 
depend upon the nature of the substance thus thrown 
into vibration, and also upon the violence with which, 
it is struck. As the object of percussion is to 
determine the physical nature of the underlying 
tissues, it is essential that variations due to differ- 
ences in the strength of the percussion stroke must he 
avoided. 

From a physical stand-point animal tissues may 
he divided into hones, soft tissues, and soft tissues con- 
taining air. On tapping, or to use the technical term, 
"percussing" a bone, we find that it can be made to 
vibrate and to give forth sounds of an intensity which 
varies with the force with which it is struck; of a pitch 
which varies with its size and shape, and of a quality 
which is sufficiently typical to be recognized from 
sounds obtained by percussion over other parts of the 
body. Bones are resonating hodies, and their percus- 



26 PHYSICAL BASIS OF AUSCULTATION 

sion yields a fairly typical sound which we call a 
bony note or osseous resonance. 

Percussion of soft tissue, whether muscle, fat, liver, 
etc., on the other hand, yields no resonance. This 
absence of resonance, called flatness, is because such 
tissues have considerable mass but very poor elasticity. 
Collections of fluid are equally devoid of resonance to 
percussion. Not only do soft tissues yield no reso- 
nance, but they also impede transmission of the per- 
cussion stroke to an underlying resonating body, and 
impede the return of sound waves from the resonator 
to the ear. A layer of rubber will mufile the loudest 
drum. 

Percussion of Air-containing Tissues. — Percussion 
yields its greatest information in dealing with soft tissues 
containing air. Over a large air-containing cavity 
the percussion note varies in intensity with the force 
employed and with the amount of intervening tissue. 
Therefore when constant force is used, the intensity 
enables us to estimate the amount of tissue intervening. 
Thus in percussion upward on the abdomen the edge 
of the liver is detected by the decreased intensity over 
that part of the stomach, or colon, which it overlies. 
With very light percussion, just sufficient to produce 
resonance over the exposed portion of the gut or 
stomach, the muffling effect of a very thin layer of 
liver may be detected. In ordinary work, however, 
the percussion of the lower liver margin is usually 
made out 2 or 3 cm. higher than the true edge. 

On the other hand, the pitch over such cavities depends 



PHYSICS OF PERCUSSION 27 

entirely upon their size. The difference between small 
intestine and a colon is detected by the abrupt fall 
of pitch on passing to the larger cavity. Ordinarily 
the air collections within the body are surrounded 
by elastic walls under moderate tension, and the 
sounds obtained by percussion are due to both air 
content and containing wall vibrating in unison. 
Should the air, however, be under high tension, the elas- 
ticy of the wall is impaired so that it has little reso- 
nance of its own and also even fails to transmit the 
vibrations of the air within. Thus, rare cases of 
pneumothorax in which a valve-like perforation of 
the lung allows air to enter but not to leave the pleural 
cavity, may give a dull note, instead of the usual 
increased resonance. This decreasing resonance, as 
the pressure within a cavity rises, can be illustrated by 
percussing the moderately and then the forcibly 
distended cheek; or better still, a pneumatic tire 
during inflation. 

Another factor occasionally enters into considera- 
tion in percussion over cavities. An organ pipe 
with open ends produces tones of twice the number 
of vibrations as that of the same pipe with the end 
closed. The leather bottle of the pool table on per- 
cussion is thus found to give a note of lower pitch 
when its neck is corked. Percussion of the cheek with 
the lips alternately opened and closed yields the same 
result. And where a pulmonary cavity communicates 
freely by a widely open bronchus, this change of pitch 
may again be frequently demonstrated by having the 



28 PHYSICAL BASIS OF AUSCULTATION 

patient alternately open and close his mouth during 
percussion. 

On percussing a beaker filled with effervescing 
liquid we obtain a beautiful drum-like (tympanitic) 
sound; while from a beaker of plain water no note 
is elicited. The difference is evidently due to the 
presence of numerous, though minute, air bubbles in 
the former. Similarly a pan of raised dough ready 
for baking gives a tympanitic note, quite like that 
obtained over a moderately tense, inflated bladder of 
similar size. With this in mind we might expect the 
J normal lung to yield sounds on percussion of the 
same drum-like, musical character. On examining 
the relaxed lung removed from the body this tympanitic 
note is found, but on percussing the normal chest a 
sound of good intensity but entirely different character, 
called pulmonary resonance (vide p. 74), is obtained. 
That the difference is not due to the chest wall is 
readily demonstrated by the percussion of a lung 
removed from the body and then inflated to its original 
size. This inflated lung gives, not a tympanitic note, 
but the peculiar sound called normal pulmonary reso- 
nance. This is because the tissue fibers of the relaxed 
lung are no more capable of maintaining a vibration 
than are the slackened strings of a violin; and merely 
follow the vibrations of the air contained within them. 
The note obtained over a relaxed lung is therefore 
identical with that found over the air-containing water 
or dough — tympanitic and varying in pitch with the 
size of the organ. On inflation, however, the stretched 



PHYSICS OF PERCUSSION 29 

lung fibers add their own vibrations to those of the air 
content; and the composite sound elicited is now no 
longer a drum-like tone, but a non-musical noise, to 
which, in the absence of any descriptive term, the 
name normal pulmonary resonance is applied. 

It is interesting to note that when the pan of risen 
dough is baked, the loaf of bread yields no longer a 
tympanitic note, but a sound very similar to normal 
pulmonary resonance; because its air content is now 
subdivided by elastic partitions capable of maintaining 
vibrations of their own. 

The Strength of the Percussion Stroke. — This may 
influence the sound elicited not only in intensity but 
also in quality. This does not apply in such simple 
resonating bodies as tuning-forks or strings. But if a 
thick-walled box is very lightly struck, we may only 
set in vibration the immediate superficial layers of 
the wood, and would therefore be unable to recog- 
nize the presence of the cavity within. To detect 
the latter, sufficient force to set it in vibration must 
be employed. Therefore in determining the height 
of the liver dome (liver dulness), where we are con- 
trasting the sound produced by chest wall and a thin 
layer of lung with that produced by chest wall plus 
a much deeper layer of lung, the percussion stroke 
should be forcible enough to arouse vibrations in the 
deeper tissue. On the other hand, a heavy stroke sets 
in motion not only tissues deeper beneath it, but also 
those over a wider surface. Even 1 or 2 inches below 
the right pulmonary border a sufficiently heavy stroke 



30 PHYSICAL BASIS OF AUSCULTATION 

may spread its vibrations to the distant lung or colon, 
yielding dull pulmonary resonance or tympany instead 
of flatness. For this reason in determining the physi- 
cal condition of superficial tissues light percussion, 
just sufficient to arouse vibrations in those tissues, 
is essential. 

PHYSICS OF AUSCULTATION OF THE LUNGS. 

Transmission of Voice, Whisper, and Breath Sounds 
Through Solid Tissues. — On listening over the larynx 
when the patient speaks, loud, clear-cut voice- sounds 
are heard with the words perfectly recognizable. 
Behind over the cervical vertebrae the same clear- 
spoken words are audible, though less intense. In 
either case the sounds are conducted well by the 
intervening tissue, and differ only in intensity, depend- 
ing on how great a distance they have had to traverse, 
but not in any other respect. If we listen over an 
area of consolidated lung we find that the voice sounds 
are much the same; still less intense, perhaps, but still 
clear. The same would be true of whispered w^ords, 
and of the breath sounds. The sound vibrations are 
in all three instancss produced at the glottis; and are 
transmitted either directly, hy the tissues of the neck, 
or downward first by the air icithin the trachea, bronchi 
and bronchioles, and then by the tissue of the consolidated 
lung, and chest wall. Although the distance which 
must be traversed by those vibrations passing down- 
w^ard to the chest wall is much greater, still their inten- 



PHYSICS OF AUSCULTATION OF THE LUNGS 31 

sity is surprisingly well maintained. This is because of 
the particularly good transmission in their course within 
the bronchial tubes. 

In ordinary cases of consolidated lung the large 
bronchi remain open so that the vibrations have but 
a relatively short distance of solid lung to traverse. 
Should the bronchi be closed with fibrinous exudate, 
however, as is the case in so-called massive pneumonia 
(vide p. 136), conduction through a much longer distance 
of solid tissue is necessary and tremendous loss of 
intensity results. 

According to the thickness of the chest wall the 
intensity of the sounds is altered for the same reason 
— because solid tissue is not a particularly good con- 
ductor. On the other hand, the sounds may be heard 
unexpectedly well at the outer end of the clavicle, 
since bones transmit much better than soft tissue. 

Transmission of Glottis-bronchial Sounds through 
Normal Lung. — The normal alveolar tissue of the 
lung offers a great obstacle to the transmission of 
sound waves. The vibrations must pass successively 
through layer after layer of alternate air and solid. 
Great loss of intensity through dispersion results. The 
sounds lose in intensity just as if they had to traverse 
a layer of felt. 

Over normal lung the whisper sounds are practically 
absent — their relatively weak vibrations being com- 
pletely blocked by the alveolar tissue. Voice sounds 
are far more intense than whisper to start with, and 
so are able to penetrate to the chest w^all, though 



32 PHYSICAL BASIS OF AUSCULTATION 

modified in two respects. Voice sounds heard over 
normal lung are less intense and also have a muffled, 
humming quality, quite distinct from the clear-cut 
sounds heard over a consoHdated area. The latter 
modification is due to secondary vibrations set up in 
the taut-drawn elastic fibers of the alveolar walls, 
which blur the distinctness of the original sound 
waves. They may be compared to the added second- 
ary sounds heard on speaking through a paper-covered 
comb, or on talking into a piano. 

The breath sounds over normal lung are very differ- 
ent from those heard at the trachea, cervical spines, 
or over an area of consolidation. What these differ- 
ences are will be considered in great detail later {vide 
p. 114). Over consolidated lung we hear the same 
breath sounds that we hear at the trachea, though less 
intense because of the distance which the vibrations, 
produced chiefly at the glottis, must travel in reaching 
the chest wall. The normal alveolar tissue, on the one 
hand, muffles and partially obliterates these glottis and 
bronchial breath sounds, just as it blocks off the sound 
waves of the whispered voice. On the other hand, the 
air entering and leaving the alveolar vesicles, and particu- 
larly the alternate stretching and relaxing of the elastic 
framework of those cells, produce the main sound vibra- 
tions which we hear over normal lung. In inspiration 
the sounds contributed by the alveoli are far more 
intense. The string that is being stretched is the 
string that complains. In vesicular breathing the 
greater intensity of the inspiratory sound seems 



PHYSICS OF AUSCULTATION OF THE LUNGS 33 

wholly of alveolar origin. In expiration, however, the 
sounds produced in the alveoli are much fainter, and 
a little of the glottis-bronchial vibrations is frequently 
audible, particularly when the patient breathes 
forcibly, or pants. 

Infiltration or Partial Consolidation of the Lungs. — This 
gives so-called bronchovesicular breathing, because 
the consolidated patches, on the one hand, conduct 
the glottis-bronchial sounds; while on the other hand, 
such areas as are normal contribute vesicular sounds 
to the respiratory murmur which is heard. 

Solid Tumor, Cyst or Abscess. — The presence of either 
of these in the lung modifies the breath sounds, first, 
by the fact that it replaces the normal lung tissue 
and therefore prevents the production of vesicular 
sounds at that point; and second, because the glottis 
and bronchial vibrations have just so much added solid 
tissue to penetrate, through which they are not con- 
ducted by open bronchioles as in ordinary consolida- 
tion. Such conditions, therefore, resemble that of 
massive consolidation ; and, if sufficiently large, oblit- 
erate all breath sounds. 

A Superficial Cavity in the Lung. — This condition 
similarly abolishes the alveolar element of the breath 
sounds at that point. If there is close contact or 
free communication with the bronchus, the glottis- 
bronchial voice, breath sound and whisper vibrations 
are well transmitted; but to them are added the over- 
tones produced by the resonator action that any such 
air space possesses. According to the intensity of the 
3 



34 PHYSICAL BASIS OF AUSCULTATION 

overtones the sounds heard are called cavernous or 
amphoric, depending on whether they are more or less 
musical. 

Pneumothorax. — The presence of air within the 
pleura usually decreases the intensity of the breath 
sounds because the vibrations have one additional 
layer to traverse. They must suffer the dispersion 
incidental to passage from tissue to air, and air back 
to tissue again, before reaching the chest wall. Also 
the lung upon the affected side is more or less thrown 
out of function by collapsing against the mediastinum, 
so that less air is flowing to and fro within its bronchi. 
Frequently that chest is motionless. 

In cases where the communication between the 
bronchi and the pleural cavity remains widely open, 
however, the sounds may be intense, consisting of the 
glottis-bronchial vibrations, which have now no need of 
passing through an alveolar layer; and also of vibra- 
tions produced at the point of connection between 
bronchus and pleural cavity. But more important 
than the intensity of breath sounds is the production 
of overtones by the resonator action of the air space, 
just as occurs in pulmonary cavities; so here extreme 
grades of amphoric or cavernous voice and breath 
sounds may be met. 

Pleural Effusions. — The presence of fluid within the 
pleural cavity modifies the signs obtained by auscul- 
tation in rather contradictory ways. As will be con- 
sidered later, the fluid does not lie in a flat layer at 
the bottom of the chest except in cases of hydro- 



PHYSICS OF AUSCULTATION OF THE LUNGS 35 

pneumothorax. In simple pleural effusions the fluid, 
though collecting somewhat beneath the lung, rises 
up laterally so as to also surround the lower portion of 
the lung, particularly posteriorly. As we cannot 
examine the diaphragmatic aspect of the thorax, we 
are especially interested with the effect of the layer 
of fluid which separates the lung from the chest wall. 
Moderate collections of fluid, which merely relax the 
adjacent lung, decrease the intensity of the breath sounds 
simply by hindering the passage of their vibrations. 
Larger collections, as they compress the adjacent 
lung, prevent the production of the vesicular element 
of the breath sounds, and in proportion as they con- 
vert the lung into a solid atelectatic state, they abolish 
the muffling action which normal alveoli exert upon 
the glottis-bronchial vibrations. Lung which is merely 
relaxed, but by no means atelectatic, conducts sounds 
far better than in the distended state; as may be 
readily verified by listening to a watch through a layer 
of relaxed and then through a layer of reinflated lung. 
Though fluid is not a good sound conductor, it is better 
than distended alveolar tissue, and the glottis- 
bronchial element of the breath sounds, though faint, 
are usually audible. The less common occurrence of 
intense bronchial breath sounds over fluid, more 
difficult of explanation, is perhaps due to the fluid 
being in direct contact with an unusually large area 
of exposed bronchus at the root of the lung, or to 
complete atelectasis. 



36 PHYSICAL BASIS OF AUSCULTATION 

ADVENTITIOUS SOUNDS. 

Certain physical changes in the lungs caused by 
disease may merely manifest themselves by altera- 
tions of intensity and quality of the respiratory mur- 
mur. In two other pathological processes we find on 
auscultation a new set of so-called adventitious sounds. 

Moist Rales. ^ — The most common adventitious sounds 
are moist rales, due to the presence of serum, mucus, or 
pus within the bronchial tubes, through which the air 
entering and leaving the alveoli, bubbles to and fro. 

The pitch of these moist rales depends upon the 
size of the tube in which the bubbling occurs. This 
may be readily shown by blowing air through a series 
of different sized rubber tubes containing soap and 
water, and the imitation is still better produced if the 
tubes be imbedded in agar, so that the ear or stetho- 
scope may be directly applied to the surface of the 
latter. Moist rales of high pitch are due to bubbles 
in the finer bronchioles, while those of the low pitch 
originate in the larger bronchi. 

While the condition of the alveoli is not concerned 
in the production of moist rales, it may modify their 
distinctness; just as in the case of other sound vibra- 
tions produced in or transmitted downward through 
the bronchi. Rales produced in the same tubes are 
muffled when heard through normal alveolar tissue, 
while they sound sharper and more crackling if their 
vibrations are better conducted by a consolidated or 
partially solidified parenchyma. The presence of 



ADVENTITIOUS SOUNDS 37 

consolidation adds nothing to the intensity of the 
original sound vibrations: it simply conducts those 
vibrations much more completely to the ear. 

Consonating Rales. — An adjacent air-containing cav- 
ity within the lung or a collection of air within the 
pleura (pneumothorax), on the other hand, adds to 
the original vibrations through its resonator action. 
The rales in this case are intensified just as are the 
sounds of fire-crackers exploding within a barrel. In 
the neighborhood of small and moderate-sized cavities 
they take on a quality to which the name consonating 
is applied, while near large cavities, and particularly 
in pneumothorax, the development of overtones is so 
pronounced that the sounds become beautiful musical 
tinkling s. 

Dry Rales. — The whistling, piping adventitious 
sounds called dry rales occur where the lumen of 
the bronchi is irregularly contracted, either by the 
presence of tenacious mucus or by actual spasm of 
the bronchial constrictors. In this case again the 
pitch depends upon the size of the bronchiole and 
the degree of contraction. High pitch points to small 
tubes. Were the decreased size of the lumen uniform 
there would be no abnormal sound. Air flowing 
through even moderately irregular tubes does not 
produce such sounds unless the velocity far exceeds 
that found within the chest. On the other hand, 
intense sound vibrations may be produced when air 
is passed, even at low velocity, through a tube whose 
lumen is sharply contracted at two or more points; 



38 PHYSICAL BASIS OF AUSCULTATION 

as may be demonstrated by a glass tube in which two 
thin perforated corks are inserted; by the well-known 
button-like whistle consisting of two perforated tin 
diaphragms separated by a small interval, or by a pill 
box whose top and bottom have been perforated. 

Crepitant Rales. — The so-called crepitant rale is 
produced within the alveoli and finest bronchioles 
when their walls, which have become agglutinated 
either through compression or by the presence of a 
viscid exudate, are again separated by a deep inspira- 
tion. They may be imitated by separating the thumb 
and forefinger after these have been squeezed together 
for a few moments. The relaxation of a tightly com- 
pressed rubber sponge produces a similar sound. 
■ Pleural Adventitious Sounds. — The simplest of these 
is the rubbing or crunching sound produced when the 
roughened surfaces in dry, fibrinous pleurisy slide 
over each other during respiration. Should these 
surfaces be separated by a layer of intervening fluid 
no friction sound can occur. It is also to be empha- 
sized that in cases of fibrous pleurisy, the surfaces are 
again covered by endothelium and friction is not 
produced. The presence of a pleural rub means that 
the surfaces are roughened by fibrin and are in contact. 

The presence of air and fluid together within the 
pleura (hydro- or pyopneumothorax) gives rise to 
adventitious sounds caused by splashing of the fluid, 
either because of movements of the heart or lung within 
the thorax, or when the patient is shaken bodily {succus- 
sion splash). The sounds heard are usually musical 



ADVENTITIOUS SOUNDS 



39 



and sleigh-bell-like, as the air space is large enough to 
be very productive of overtones. 

In cases of simple pleural effusion, and in those of 
pure pneumothorax, no sounds are produced within the 
pleura. Splashing and dripping sounds can only occur 
where air and fluid are both present. The bottle com- 
pletely filled with fluid is as silent as the bottle which 
is absolutely empty, shake it as you may. 

Analysis of the fundamental notes of the different 
sounds obtained on auscultation and percussion give 
the following results (F. Miiller) : 

vibrations 

per second. Keynote. 

[ 5000 
Metallic tinkling (overtones) ....■{ 2048 

[ 1024 
Bronchial voice and breathing . . . . 512 
Tympanitic note over abdominal viscera (not \ 256 

pneumothorax) j 128 

120 



Normal 

percussion resonance: 



Vesicular 

breath sounds: 



108 
95 

85 
80 
72 
64 
32 
16 



c'- 

c 
B 
A 
G 
F 
E 
D 
C 

Cx 

C2 



The muscular element of the heart sound has a 
vibration rate of about 60. The valvular sounds and 
murmurs have a pitch about that of vesicular breath- 
ing, i. e,, 60 to 160 per second. The vibrations of 
vocal fremitus have a rate of about 100 per second. 



CHAPTER II. 

ANATOMICAL, PHYSIOLOGICAL AND PATHO- 
LOGICAL PRINCIPLES INVOLVED IN 
PERCUSSION AND AUSCULTATION. 

Definition of percussion and auscultation — The sounds 
obtained by these methods of representing healthy and morbid 
physical conditions — Definition of signs — The basis of our knowl- 
edge of signs is the constancy of association of certain sounds 
with certain physical conditions in health and disease — The 
present state of perfection of our knowledge of signs furnished 
by auscultation and percussion — Requirements for the success- 
ful study of these methods of exploration — The anatomy and 
physiology of the chest — An enumeration of the points relating 
thereto which are of special importance — The physical condition 
incident to the different diseases of the chest: the conditions 
relating to the respiratory system stated, and a summary of 
them — The distinctive characters of healthy and morbid signs; 
variations in intensity, pitch, and quality, considered as the 
chief source of the character distinguishing the signs of disease 
from each other and frpm those of health — Other distinctions 
than those of intensity, pitch, and quality — The analytical 
method of the study of auscultation and percussion — The 
significance of signs as regards the physical conditions which they 
severally represent — Morbid conditions, not individual diseases, 
represented by the morbid signs — Regional divisions of the 
chest — Anatomical relations of the regions severally to the parts 
within the chest. 

PHYSICAL EXPLORATION. 

The physical examination of the chest embraces 
six different methods — namely, inspection, palpation, 
me'nsuration, percussion, auscultation, and succussion. 



PHYSICAL EXPLORATION 41 

Of these percussion, auscultation, and succussion 
involve the sense of hearing. In percussion the sounds 
are produced by striking upon the walls of the chest; 
in auscultation they are caused by acts of breathing, 
speaking, and coughing; in succussion they are caused 
by splashing of fluids when the body is shoved abruptly 
or shaken. 

The sounds in auscultation and percussion are (1) 
normal or healthy sounds, being produced when there 
is no disease of the chest; and (2) abnormal or morbid 
sounds, being produced when the chest is the seat of 
disease. The sounds, healthy and morbid, constitute 
what are known as physical signs. Frequently, for 
the sake of brevity, the term signs,' without the word 
physical, is used to denote these sounds. Conven- 
tionally, physical signs, or signs, are terms employed 
in a sense of contradistinction to the term symptoms. 
The latter term is then restricted to include those 
abnormal conditions detected by the patient but not 
objectively demonstrable. The signs are distinguished, 
of course, as normal or healthy, and abnormal or 
morbid. 

The representation of healthy and morbid physical 
conditions by certain healthy and morbid signs is 
established by having ascertained a constancy of 
association of the signs with the conditions. This 
constancy of association is ascertained by observation 
or experience. The sounds obtained by percussion 
and auscultation in health are thereby established 
signs of healthy conditions; and the sounds obtained 



42 PERCUSSION AND AUSCULTATION 

only in cases of disease are thereby established signs 
of morbid conditions. Our knowledge of certain 
sounds as the signs of certain physical conditions can 
have no reliable basis other than the constancy of 
the connection of the former with the latter. This 
constancy of connection is determined by the study 
of the sounds during life and examination of the 
organs after death. The existence of certain condi- 
tions is not to be inferred from the characters of 
certain sounds until the connection of the sounds 
with the conditions has been ascertained by experi- 
ence; then, and then only, are the sounds to be reck- 
oned as signs of these conditions. So, also, it is not 
to be inferred from certain physical conditions found 
after death that certain sounds must have been 
produced during life, until the connection between 
the conditions and the sounds has been ascertained 
by experience. In other words, our knowledge of 
signs as representing physical conditions, can rest on 
no other than a purely empirical foundation. 

Our knowledge of the signs representing the phys- 
ical conditions in health and disease, thanks to the 
labors of Laennec, and of those who have followed 
in his footsteps, has been brought to great perfec- 
tion.^ The practical object of this knowledge is to 
determine by means of auscultation and percussion, 
together with the other methods of exploration, the 

^ We owe a debt also to Auenbrugger, who preceded Laennec, 
and to Wintrich, Skoda, Traube, and Gerhardt, particularly 
among his successors. 



ANATOMY OF RESPIRATORY ORGANS 43 

existence of either healthy or morbid physical condi- 
tions, and to discriminate the latter from each other; 
that is to say, the practical object is diagnosis. The 
signs now known to represent physical conditions, 
healthy and morbid, taken in connection with symp- 
toms and pathological laws, render, for the most part, 
the diagnosis of diseases of the chest easy and posi- 
tive. Hence, it becomes the duty of the medical 
student and practitioner to give to auscultation and 
percussion attention sufficient, at least, for their 
practical application to the diagnosis of the diseases 
commonly met with in medical practice. In entering 
upon the undertaking it is important to consider the 
requirements for the successful study of this province 
of practical medicine. These requirements relate to: 
(1) the anatomy and physiology of the chest; (2) the 
morbid physical conditions incident to the different 
diseases of the chest; (3) the distinctive character of 
healthy and morbid signs ; and (4) the significance 
of the signs as regards the physical conditions which 
they severally represent. 

ANATOMY AND PHYSIOLOGY OF THE RESPIRA- 
TORY ORGANS. 

The necessity of a knowledge of the anatomy and 
physiology of the chest, as a requirement for the 
study of auscultation and percussion, together with 
the other methods of physical exploration, is too 
obvious to need any discussion. The physical con- 



44 PERCUSSION AND AUSCULTATION 

ditions- of health must be known as preparatory for 
appreciating the physical conditions of disease. The 
student, therefore, who is not acquainted with the 
anatomy and physiology of the chest, must defer 
entering upon the study of physical diagnosis until 
this requirement is fulfilled. 

Familiarity with the morbid physical conditions is 
necessary; and it is advisable to refresh the memory 
with a review of certain anatomical and physiological 
points before beginning the study of auscultation and 
percussion. These points, relating especially to the 
physical conditions of health, cannot be considered in 
this work. A simple enumeration of them only can be 
introduced. 

Important anatomical conditions relate to the 
bones of the chest — namely, the general conforma- 
tion of the thorax, the differences in respect to the 
obliquity of the ribs from above downward; the direc- 
tion of the costal cartilages, their connection with 
the sternum, and the angles formed by the junction 
of the ribs and cartilages; the differences in width 
of the intercostal spaces in the upper, middle, and 
lower portions of the anterior, lateral, and posterior 
aspects of the thorax, together with the relations of 
the scapula and clavicle. The relative thickness 
of the muscular covering of the chest in different 
situations is to be considered, and, in women, the 
varying size of the mammae. The attachments of 
the diaphragm to the thoracic walls, and its relations 
to the organs below, as well as above it, are points of 
importance (Figs. 5, 6, 7, 8). 



ANATOMY OF RESPIRATORY ORGANS 45 

Important physiological conditions relate to the parts 
which the ribs, costal cartilages, sternum, and diaphragm 
play in the movements of respiration. The differences 
of these movements in tranquil and in forced breathing; 
the contrast between the two sexes, and between early 
and advanced life, are points to be studied. Other 
points are the frequency of the respirations in health, 
and the relative duration, rapidity, and force of the 
inspiratory and the expiratory movements. 

Certain anatomical and physiological points per- 
tain to the organs within the chest. The more impor- 
tant of these, relating to normal physical conditions, 
are the following: 

(1) As regards the lungs, the connections of the 
pleura, and the smoothness of the pleural surfaces in 
contact with each other; the relations of the apex 
and base of each lung to the chest walls, and the 
differences of the two lungs in this respect; the rela- 
tive spaces occupied respectively by the two lobes 
of the left, and the three* lobes of the right lung; 
the situation of the interlobar fissures in either side 
on the posterior, lateral, and anterior aspects of the 
chest; the arrangement of the air vesicles, pulmonary 
lobules, and the different-sized intrapulmonary bron- 
chial tubes; the expansion of the air vesicles, and the 
movement of the current of air from larger to smaller 
bronchial tubes in the act of inspiration; the vesicles 
diminishing in size, and the current of air moving 
from smaller to larger tubes in the act of expiration; 
the difference in respect to the relative proportion 



46 PERCUSSION AND AUSCULTATION 

of air and solids at the end of inspiration and at the 
end of expiration; the extent to which the volume 
of the lungs may be diminished by a forced act of 
expiration, and increased by a forced act of inspira- 
tion; the relations of the apices to the trachea, and to 
the subclavian arteries; and the variable extent to 
which the apex rises on either side above the clavicle. 

(2) As regards the larynx, trachea, and the bronchial 
tubes without the lungs; the anatomy and physiology 
of the vocal chords; of the muscles concerned in the 
movements of respiration and of phonation, with the 
relations of each to the recurrent laryngeal nerve; the 
size of the rima glottidis in youth, after puberty, and 
relatively in the two sexes; the enlargement of the 
rima in the act of inspiration, the diminution of its 
size in the act of expiration, and the closer approxi- 
mation of the chords in the act of coughing; the 
difference in the amount of areolar tissue above the 
vocal chords in children and in adults; the situation 
of the trachea and the point of its bifurcation; the 
length, direction, and size of the two primary bronchi 
contrasted with each other, and the branches which 
penetrate the lungs. 

(3) As regards the heart, the boundaries of the space 
which it occupies — that is, of the precordial space; the 
relation of the aorta and pulmonic artery to the walls 
of the chest; the portions of the precordial space in 
which the heart is covered and uncovered by lung; 
the situations of the auricles and ventricles respectively; 
the relations of these to each other, and the arrange- 



DISEASES OF THE RESPIRATORY SYSTEM 47 

ments of the valves; the currents of blood through the 
orifices within the heart, and the relations of each of 
these to the heart sounds ; the rhythmical succession of 
these sounds; the differences which distinguish each 
from the other, and the situation in which each has its 
maximum of intensity ; the mechanism of these sounds, 
and the situation of the apex beat (Figs. 5, 6, 7, 8). 

The foregoing are the anatomical and physio- 
logical points which especially claim attention with 
reference to normal physical conditions. It is recom- 
mended to the student, before proceeding further, to 
acquire knowledge respecting all these points, by 
reference to works treating of the anatomy and 
physiology of the chest. 

THE MORBID PHYSICAL CONDITIONS INCIDENT 
TO THE DIFFERENT DISEASES OF THE RESPI- 
RATORY SYSTEM. 

The various morbid physical conditions incident 
to different diseases must be known, for it is the 
immediate object of auscultation, percussion, and the 
other methods of exploration, to ascertain either 
the existence or the absence of these morbid con- 
ditions. Knowledge of all the important conditions 
which are deviations from those of health, and the 
relations of each to different diseases, is therefore 
an essential requirement. 

Deviations from the normal conformation of the 
chest and the various abnormal movements of respi- 



48 PERCUSSION AND AUSCULTATION 

ration, belong properly among the physical signs 
obtained by inspection, palpation, and mensuration. 
For the most part these signs represent morbid 
physical conditions within the chest. 

Certain conditions relate to the presence of liquid, 
' either serous, serofibrinous, or purulent, within the 
pleural sac. The quantity of liquid may be large 
enough to compress the lung into a solid mass, and to 
enlarge the affected side, at the same time restraining 
or annulling the respiratory movements; the chest on 
the affected side, then, will contain only lung solidified 
by compression, and liquid. In other cases the quan- 
tity of liquid is either small, moderate, or considerable, 
the lung then containing a lessened quantity of air, 
and its volume diminished in proportion to the amount 
of liquid. These morbid conditions are incident to 
simple pleurisy with effusion, pyothorax or empyema, 
and hydrothorax. 

The pleural surfaces, in cases of pleurisy, may be 
more or less covered with recent fibrinous exudation, 
and, when not separated by the presence of liquid, 
they do not move upon each other smoothly and 
noiselessly. The friction of the opposed surfaces is 
still more productive of audible and sometimes tactile 
signs after the absorption of liquid, when the fibrinous 
exudation has become more adherent and dense than 
when it is recent. Should this exudate become organ- 
ized and its surface covered with endothelium, however, 
there will, of course, be no friction. 

The presence of air in the pleural space, either 



DISEASES OF THE RESPIRATORY SYSTEM 49 

alone or with more or less liquid, in pneumothorax, 
may compress the lung into a solid mass, also dilat- 
ing the affected side, and restraining or annulling its 
movements; and the air, with or without liquid, when 
not in sufficient quantity to produce these effects, 
may diminish more or less the volume of the lung 
and the amount of air in the pulmonary vesicles. 
These morbid conditions give rise to characteristic 
physical signs. The perforation of lung, usually exist- 
ing in cases of pneumothorax may become closed as 
the lung collapses. If, however, a free communica- 
tion from the bronchi to the pleural cavity remains 
open, it occasions additional signs which are charac- 
teristic. 

Solidification of lung is an important physical 
condition incident to several diseases, irrespective 
of the condensation, caused by the compression of 
liquid or air in the pleural sac. Complete consolida- 
tion of an entire lobe, or of two and even three lobes, 
exists in the second stage of lobar pneumonia. Cer- 
tain physical signs represent this condition of complete 
solidification.^ The different degrees of solidification, 
namely, slight, moderate, and considerable, occur dur- 
ing the stage of resolution in cases of pneumonia, and 

1 The term complete consolidation as used here is not intended 
to indicate a filling of the large subdivisions of the bronchi with 
exudate in the a;ffected lobe. This extreme condition may occur 
and is described as massive consolidation. In this form certain 
of the physical signs are markedly altered, the breath and voice 
sounds being diminished or entirely suppressed. 
4 



50 PERCUSSION AND AUSCULTATION _ 

these gradations are represented by well-defined 
physical signs. Solidification, circumscribed, forming 
nodules which vary in size and number, situated 
in the upper, lower, or middle portion of the lung, 
either on one side or on both sides, exists in phthisis, 
in bronchopneumonia and collapse of pulmonary 
lobules, in hydatids, in hemorrhagic infarcts and 
embolic pneumonia, in pulmonary gangrene, and in 
primary and secondary neoplasms. It exists, greater 
or less in degree, in interstitial pneumonia. In these 
different conditions the existence of solidificatioji, its 
degree and extent, are determinable by means of 
physical signs. 

A morbid condition the opposite of solidification 
is an abnormal accumulation of air within the air 
vesicles of the lungs. This is incident to pulmonary 
emphysema, involving a morbid dilatation of the air 
vesicles. The permanent expansion and increased 
volume of the upper lobes in some cases of this dis- 
ease occasion a characteristic deformity of the chest, 
together with abnormal movements of respiration, 
which are also characteristic. This is represented by 
distinctive signs furnished by auscultation and percus- 
sion. The extravasation of air in the connective tissue, 
constituting interlobular and subpleural emphysema, in 
like manner gives rise to signs furnished by these 
methods of exploration. 

The presence of a viscid exudation within the air- 
vesicles and bronchioles, occurs in acute pneumonia, 
especially in its first stage, causing the w^alls of the 



DISEASES OF THE RESPIRATORY SYSTEM 51 

alveoli and bronchioles to stick together when emptied 
at the end of expiration. The separation of these 
adherent walls, in the act of inspiration, gives rise to 
an auscultatory sign (the crepitant rale). 

An accumulation of serum within the air vesicles 
constitutes the condition called pulmonary edema. 
This condition gives rise to signs furnished by auscul- 
tation and percussion. 

Liquid within the bronchial tubes (serum, pus, 
blood, or thin mucus) is a condition incident to pul- 
monary edema, abscess either of the lung, or situated 
elsewhere and evacuating through the bronchial 
tubes, phthisis, bronchorrhagia, pneumorrhagia, bron- 
chorrhea, and bronchitis. The passage of air through 
the liquid in the tubes causes bubbling sounds which 
are appreciable in auscultation. The apparent size 
of the bubbles (coarseness or fineness) denotes the 
size of the tubes in which they are produced, and the 
pitch of the bubbling sounds denotes either solidifica- 
tion or otherwise of the pulmonary substance surround- 
ing the tubes in which the bubbles are produced. 

The presence of tenacious mucus and the swelling 
of the mucosa in cases of bronchitis may cause dimin- 
ished calibre of the bronchial tubes in localized or dif- 
fuse areas. In cases of so-called capillary bronchitis 
the condition may involve an alarming degree of ob- 
struction. The same morbid condition is incident to 
bronchial spasm in asthma, occasioning in this disease 
great suffering, but without immediate danger. The 
auscultatory signs enable the auscultator to diiferen- 



52 PERCUSSION AND AUSCULTATION 

tiate the obstruction due to capillary bronchitis from 
that due to bronchial spasm. Permanent obliteration 
of more or less of the bronchial tubes is an occasional 
morbid condition. 

Obstruction of a bronchial tube, either within or 
without the lung, is a morbid condition involving 
the loss of respiratory sound within the area of the 
bronchial branches and vesicles not receiving air in 
consequence of the obstruction. The obstruction 
may be temporary, being caused by a plug of mucus 
of sufficient size to prevent the passage of air; the 
morbid condition is then incident to bronchitis. One 
of the primary bronchi may be obstructed temporarily 
by a plug of mucus, and obstruction of the larynx 
in childhood thus produced may be sufficient to cause 
death by suffocation. Foreign bodies within the 
larynx, trachea or bronchi cause similar obstructions. 
A primary bronchus or the trachea may be pressed 
upon by an aneurismal or other tumor, and in this 
way more or less obstruction to the passage of air is 
produced. However produced, the situation of the 
obstruction and its degree are, in general, determin- 
able by means of auscultatory signs. 

Dilatation of bronchial tubes occasions two morbid 
physical conditions differing as regards their auscul- 
tatory signs — namely, (1) an enlargement of greater 
or less extent, the tubes preserving their cylindrical 
form; and (2) a sacculated enlargement. The former 
occurs generally in connection with solidification 
around the tubes from hyperplasia of the areolar 



DISEASES OF THE RESPIRATORY SYSTEM 53 

tissue, and is thus incident to interstitial pneumonia. 
The latter when emptied of accumulated secretions 
may give rise to signs which represent pulmonary 
cavities. 

Sacculated dilatations of bronchial tubes and the 
cavities incident to phthisis, pulmonary abscess and 
circumscribed gangrene of lung, are represented by 
well-marked and highly distinctive signs. The signs 
denote either that cavities have flaccid walls which 
collapse in expiration and expand in inspiration, or 
that, owing to solidification of lung, they remain open 
during both acts of respiration. 

More or less of the space within the chest which, 
normally, is occupied by lung, may be encroached 
upon by aneurisms or other tumors, giving rise to 
notable morbid signs furnished by auscultation and 
percussion. 

Finally, an extremely rare morbid physical con- 
dition is the presence of more or less of the hollow 
viscera of the abdomen within the chest, in con- 
sequence of either a congenital deficiency in the 
diaphragm, or a wound penetrating this muscle 
(diaphragmatic hernia) . 

The foregoing morbid physical conditions relate 
to the respiratory organs. Those relating to the 
heart are deferred in order that they may precede 
more immediately an account of the signs of cardiac 
disease. As a requirement for the study of morbid 
physical signs the foregoing morbid physical con- 
ditions must be understood and memorized. 



54 PERCUSSION AND AUSCULTATION 

SUMMARY OF MORBID PHYSICAL CONDITIONS 
INCIDENT TO DISEASES OF THE RESPIRA- 
TORY ORGANS. 

1. An accumulation of serous, serofibrinous, or 
purulent liquid within the pleura sufficient to fill the 
affected side of the chest, compress the lung, and some- 
times causing more or less enlargement. 

2. An accumulation of liquid partially filling the 
-affected side of the chest, the quantity being either 
small, moderate, or considerable. 

3. Fibrinous exudation on the pleural surface^ 

4. Fibrous thickening of the pleura. 

5. Air with liquid within the pleural cavity, with 
or without free communication between bronchus 
and pleura. 

6. Air without liquid in the pleural cavity. 

7. Solidification of lung, either complete or approxi- 
mating to completeness. 

8. Partial solidification of lung, slight or moderate 
in degree. 

9. Dilatation of the air vesicles, involving within 
them an abnormal accumulation of air. 

10. Extravasation of air within the pulmonary con- 
nective structure. 

11. Exudation within air vesicles and bronchioles. 

12. Liquid within air vesicles. 

13. Liquid (mucus, serum, pus, or blood) within 
bronchial tubes of large, medium, or small size. 

14. Liquid within bronchial tubes of minute size. 



CHARACTERS OF MORBID SIGNS 55 

15. Obstruction of the pulmonary bronchial tubes 
by mucus, swelling of the mucous membrane, and 
spasm' of the bronchial muscular fibers. 

16. Obstruction of larynx, trachea, or bronchi 
exterior to the lungs by plugs of mucus or foreign 
bodies. 

17. Obstruction of the trachea or a primary bron- 
chus by aneurismal or other tumors. 

18. Dilatation of bronchial tubes, cylindrical or 
sacculated. 

19. Pulmonary cavities. 

20. Tumor within the chest, pulmonary abscess, 
and cysts. 

21. Diaphragmatic hernia. 

THE DISTINCTIVE CHARACTERS OF HEALTHY 
AND MORBID SIGNS. 

For the practice of auscultation and percussion it is 
essential to be able to recognize the signs, severally, 
which represent the different physical conditions in 
health and disease. The recognition and discrimina- 
tion of signs require knowledge of the distinctive 
characters belonging to each of them. In entering 
upon the study of the signs, therefore, it is a neces- 
sary requirement to know whence their distinctive 
characters are derived. To this point of inquiry the 
attention of the student is now invited. 

The signs being sounds, they are to be recognized 
and discriminated in the way in which we practically 



56 PERCUSSION AND AUSCULTATION 

recognize and discriminate other sounds. In becom- 
ing familiar with other sounds, for example, musical 
notes produced by different instruments, or the 
varieties of the human voice, we do not have recourse 
to the science of acoustics. It suffices for all practical 
purposes to contrast the sounds obtained by auscul- 
tation and percussion with reference to very simple 
and obvious differences. The differences between the 
sounds obtained by auscultation and percussion relate 
to intensity, pitch, quality, and duration. 

Differences in the intensity of sounds depend upon 
the si^e of the vibration waves which reach the ear. 
One sound is more intense than another sound when 
it is simply louder, and varying degrees of intensity 
are expressed by such terms as feeble or weak and 
loud, to which may be prefixed adjectives of quantity, 
such as very, moderate, etc. 

Differences in the pitch of sounds are easily under- 
stood by those who have given any attention to music. 
They depend upon the rate of vibration of the sound- 
ing body. The differences are expressed by the 
terms high and low. A nice appreciation of varia- 
tions in the pitch of musical notes requires what is 
known as a "musical ear;" but this is not essential in 
comparing, as regards pitch, the sounds studied in 
auscultation and percussion. For the most part these 
sounds are not musical notes, and a musician might 
correctly state that noises have no pitch; nevertheless, 
differences in pitch are readily perceived. In dis- 
tinguishing two such noises we are really comparing 



CHARACTERS OF MORBID SIGNS 57 

the pitch of the lowest tone present in each. A musi- 
cal ear is undoubtedly an advantage, but it is by no 
means a sine qua non. Differences in pitch now 
enter pretty largely into the distinctive characters 
of physical signs ;^ but by Laennec, and those who 
immediately followed him, comparatively little atten- 
tion was paid to the study of signs with reference to 
these differences. 

Differences relating to quality are apt, at first, to 
be confounded with those relating to pitch; hence 
the distinction between pitch and quality must be 
clearly understood. We may say of the quality of 
a sound, that it embraces whatever is not embraced 
in the terms intensity, pitch, and duration. This is 
true as a general statement. The sense of the term 
quality, in distinction from intensity and pitch, may 
be most readily made clear by an illustration. We 
recognize at once an unseen instrument by the notes, 
provided it be one with which we are familiar, such 
as a violin, a flute, a clarinet, etc. Now, how do 
we recognize it? Certainly not by the intensity of 
the sounds; it matters not whether these be loud or 
weak, so that we hear them. Certainly not by the 
pitch; for if a piece of music be performed, we get both 
high and low notes. We recognize the instrument by 
the quality of the sounds. Each musical instrument, 

^ The contributions of Dr. Flint to this subject cannot be 
appreciated by those unfamihar with his essay, "Variations of 
-^Pitch in Percussion and Respiratory Sounds, and Their AppU- 
cation to Physical Diagnosis," Tr. Am. Med. Assn., 1852. 



58 PERCUSSION AND AUSCULTATION 

owing to its peculiarity of construction, yields sounds 
which are peculiar to it, depending upon the power of 
its resonator to intensify special sets of overtones. 
After we have become familiar with the quality of 
sounds peculiar to an instrument we immediately 
thereby recognize it. Precisely in the same way we 
may recognize certain sounds produced by ausculta- 
tion and percussion in health and disease. The signs 
differ in quality according to the physical conditions 
which they represent; and differences in quality 
will be found hereafter to constitute essential and 
obvious distinctions by which the signs of health and 
disease are recognized and discriminated. 

Only by direct observation can onie form a definite 
idea of the peculiar quality of any particular sound. 
That is to say, no one could clearly describe to another 
the peculiar quality of a particular sound without the 
sound having been heard. Imagine the attempt to 
describe the sound of a violin to a person who had 
never listened to the notes from that instrument. 
The only way in which an approximate idea could 
be conveyed in words would be by comparing the 
quality to that of some other instrument — that is, 
by analogy. To attempt to describe the quality of 
sounds to one who had never heard them would be 
like describing colors to one blind. It will be seen 
hereafter that the quality of certain sounds obtained 
by auscultation and percussion is peculiar to them, 
and their distinctive characters in this respect can be 
known only by direct observation. 



CHARACTERS OF MORBID SIGNS 59 

Appreciable variations in the quality of sounds 
are infinite. This may be illustrated by the human 
voice. Almost every person may be recognized from 
a peculiar quality of the voice by one who is familiar 
with it; and the voices of thousands of persons, if 
compared, would present shades of difference. As 
the diversity in quality of different sounds cannot 
be described, so they can onh^ be designated by names 
which are significant from certain resemblances. 
Terms based on analogies are the following: rough, 
harsh and rude, soft, blowing, hollow, musical, moist, 
dry, bubbling, gurgling, crackling, clicking, rubbing, 
grating, creaking, tubular, cracked metal, sibilant or 
whistling, sonorous or snoring. All these names owe 
their significance to resemblances to other sounds. 
One sound furnished both by auscultation and percus- 
sion has a quality which is sui generis, and the term 
used to distinguish it is derived from its source, namely, 
the vesicular resonance, and the vesicular murmur of 
respiration. 

In addition to intensity, pitch, and quality as 
sources of the distinctive characters of the signs 
furnished by auscultation and percussion, there are 
some other points of difference, namely, the duration 
of certain sounds; their continuousness or otherwise; 
their apparent nearness to, or distance from, the ear; 
their rhythmical succession, and their strong resem- 
blance to particular sounds, such as the bleating of 
the goat, the chirping of birds, etc. These points of 
difference are important, although less so than those 
relating to intensity, pitch, and quality. 



60 PERCUSSION AND AUSCULTATION 

The study of these different sounds with reference to 
intensity, pitch, and quality, distinct signs being deter- 
mined from points of difference as regards these charac- 
ters, may be distinguished as the analytical method in 
contrast with the determination of signs deductively. 
If we undertake to decide, a priori, that certain sounds 
must be furnished by auscultation and percussion when 
certain conditions are present we shall be led into error; 
and so, equally, if we undertake to conclude from the 
nature of the sounds that they must represent certain 
conditions. The only reliable method is to analyze the 
sounds with reference to differences relating especially 
to intensity, pitch, and quality, and to determine differ- 
ent signs by these differences. The import of each of 
the signs must then be established by the constancy of 
association with physical conditions. 

THE SIGNIFICANCE OF THE SIGNS AS REGARDS 
THE PHYSICAL CONDITIONS WHICH THEY 
SEVERALLY REPRESENT. 

For the successful employment of the methods of 
auscultation and percussion, in addition to the 
recognition of each sign by its distinctive characters, 
must be known its significance, that is, the physical 
condition which it represents. The signs furnished by 
these methods may be said to constitute a language 
with a very small vocabulary; or, taking as the stand- 
point the things signified, the different physical condi- 
tions are expressed by means of the signs. 



SIGNS OF PHYSICAL CONDITIONS 61 

The significance of the morbid signs relates, not to 
diseases, but to the physical conditions incident 
thereto. Very few signs are directly diagnostic of any 
particular disease. They represent conditions not 
peculiar to one, but common to several diseases. 
Thus, solidification of lung exists in pneumonia, 
phthisis, pleurisy with effusion, collapse, and pul- 
monary neoplasm; now, certain signs tell us that this 
morbid condition exists, together with its situation, 
its degree, and its extent. With this information the 
diagnosis of the disease is made by connecting with 
it pathological laws, together with the history and 
symptoms. The student in physical exploration 
should by no means imagine that for the diagnosis 
of diseases exclusive reliance is to be placed on the 
signs; they are always to be taken in connection with 
pathological laws, the history, and the symptoms. 
Disconnected from these the signs would often lead 
to error, and it is no disparagement to physical diag- 
nosis that its reliability depends on other facts than 
those which belong exclusively to it. 

To repeat a statement already made more than 
once, the significance of the signs, as regards the 
conditions which they severally represent, is based 
on the constancy of their association with the latter, 
our knowledge of this association being derived from 
examinations during life and after death. 



62 



PERCUSSION AND AUSCULTATION 



REGIONAL DIVISIONS OF THE CHEST. 

Before entering on the study of physical explora- 
tion the student should become acquainted with the 
divisions of the surfaces of the anterior, posterior, 




Fig. 5. — Outlines of vicera: Lungs and interlobar lines (dotted 

line ); pleura (broken line ); heart and great vessels 

(double line =) ; liver (solid line ) ; stomach shaded. (From 

Fishberg.) 



REGIONAL DIVISIONS OF THE CHEST 



63 



and lateral aspects of the chest into circumscribed 
spaces which are called regions. 




Fig. 6. — Outlines of vicera: Lungs and interlobar line (dotted 

line ); pleura (broken line ); liver and spleen (solid 

line ■); kidneys (dot dash line ). (From Fishberg.) 



Anteriorly the chest is divided into regions as 
follows: The supraclavicular region extends from the 



64 



PERCUSSION AND AUSCULTATION 



clavicle upward a short distance, corresponding to the 
variable height to which the lung rises above this bone. 




Figs. 7 and 8. — Margins of lungs and of individual lobes 

(dotted line ) ; limits of pleura (broken line ) ; liver and 

spleen (solid line ) ; diaphragm (starred line ****); stomach 

(portion not covered by lung) shaded. (From Fishberg.) 



The clavicular region embraces the space occupied by 
the clavicle. The infraclavicular region extends from 



REGIONAL DIVISIONS OF THE CHEST 65 

the space between the clavicle to the third rib. The 
mammary region is bounded above by the third and 
below by the sixth rib, and the inframammary region 
is the portion of the chest below the sixth rib. 

Posteriorly the divisions are into the scapular, 
the infrascapular (bases), and interscapular regions. 
The scapular region is divided by the spinous ridge 
into the upper and lower scapular space, usually spoken 
of as the supra- and infraspinous areas. The infra- 
scapular region or base is the portion below a hori- 
zontal line intersecting the lower angle of the scapula. 
The interscapular region is the space between the 
posterior margin of the scapula and the spinal column. 

Laterally there are two regions, namely, the axillary 
and the infra-axillary. The axillary region is the 
space above a horizontal line extending from the 
lower border of the mammary region, i. e., the sixth 
rib. The infra-axillary region is the portion below 
the axillary region. 

The portion of the anterior surface occupied by 
the sternum is divided at the third rib into the upper 
and the lower sternal region, the space above the 
sternal notch being the suprasternal region. 

In order to become familiar with the foregoing 
regional divisions, it is recommended to the student 
to delineate them with a skin pencil on the chest of 
the living subject or a cadaver, and to study sections, 
extending from the surface to the centre of the chest, 
so as to become familiar with the relation of each 
section to the parts contained within it. The more 
5 



66 PERCUSSION AND AUSCULTATION 

important of the anatomical relations of the different 
regions are as follows : 

1. Supraclavicular Region. — This is relative to the 
upper extremity or apex of the lung, which arises 
above the clavicle in different persons from half an 
inch to an inch and a half. The height is generally 
greater on one side, and this side is usually the left. 




Fig. 9. — Position of the trachea, main and proximal subdivisions 
of the bronchi in relation to the ribs and sternum. 

2. Clavicular Region. — A small portion of the lung 
at or near the apex is contained in this region. 



REGIONAL DIVISIONS OF THE CHEST 



67 



3. Infraclavicular Region. — The parts situated here, 
exclusive of the upper sternal region (vide Fig. 5), 
are the upper portion of the lung, and the extra- 
pulmonary bronchi. The difference between the pri- 
mary bronchi, as regards direction, size, and length, 
are important points in the study of this section 
(Figs. 9 and 10). 




Fig. 10. — Position of the trachea, main and proximal divisions of 
the bronchi in relation to the ribs and vertebral column. 



4. Mammary Region. — The differences between the 
two sides in this region are important. These differ- 
ences relate especially to the precordia, and are 



68 PERCUSSION AND AUSCULTATION 

involved in the physical diagnosis of enlargement 
of the heart. The commencement of the interlobar 
fissures is in this region. On the left side the fissure 
is between the fifth and sixth ribs. On the right 
side the fissure between the upper and middle lobes 
begins at the fourth costal cartilage, and between the 
middle and lower lobes a short distance below. The 
situation of the fissures, however, differs considerably 
during the acts of inspiration and expiration. The 
liver reaches the fifth rib on the right side. 

5. Inframammary Region. — This region differs in its 
anatomical relations considerably on the two sides of 
the chest. On the right side the liver pushes upward 
the diaphragm nearly or quite to the upper boundary 
of the fifth rib. On the left side the section corre- 
sponding to the region embraces, together with the 
anterior portion of the lower lobes of the lung, por- 
tions of the stomach, spleen, and the left lobe of 
the liver. The variable volume of the stomach at 
different times occasions considerable variations in 
the relative spaces occupied by these different parts. 

6. Suprasternal Region. — This region is in relation 
to the trachea. 

7. The Upper Sternal Region. — The left innominate 
vein and aortic arch are in relation to the manubrium. 
The bifurcation of the trachea is beneath the sternum 
at the centre of a line connecting the second ribs. 
Below this line the lungs on the two sides are nearly in 
contact at the midline, covering the primary bronchi. 



REGIONAL DIVISIONS OF THE CHEST 69 

8. Lower Sternal Region. — The sternum in this 
region covers a large portion of the right and a Httle 
of the left ventricle, which lies behind the right in 
this region. 

9. Scapular Region. — ^The sections corresponding to 
this region contain the posterior portion of the upper 
lobe and a portion of the upper part of the lower lobe 
of the lung. At the upper part of the lower scapular 
(infraspinous) space terminates the fissure separating 
the upper from the lower lobe. The line of this 
fissure pursues an oblique course to the fourth or fifth 
rib on the anterior aspect of the chest. Its course 
posteriorly is roughly indicated by the vertebral border 
of the scapula when the hand is placed upon the oppo- 
site shoulder with the elbow raised. 

10. Infrascapular Region. — On the right side the 
lung extends from the upper boundary of this region 
to the eleventh rib, the liver lying in contact with 
the chest wall up to the latter point. On the left side 
the section contains a portion of the spleen. 

11. Interscapular Region. — The trachea extends in 
this section to the fourth dorsal vertebra where it 
bifurcates.^ Below this point on the two sides are 
situated the primary bronchi. 

12. Axillary Region. — ^The section corresponding to 
this region contains a portion of the upper lobe with 
large bronchial tubes. 

^ The position of the trachea and bronchi in relation to the 
bony point of the thorax is probably more accurately indicated 
in the diagrams of Dr. Blake (Figs. 9 and 10) than in the text. 
Amer. Jour. Med. Sci., March, 1899. 



70 PERCUSSION AND AUSCULTATION 

13. Infra-axillary Region. — This is in relation to the 
upper part of the liver on the right side, and on the 
left side to a portion of the spleen and stomach. 
The remainder of the section is occupied by lung. 

It is recommended to the student to become familiar 
with the sections corresponding to the different regions, 
by dissections for this purpose, and the study of 
anatomical illustrations (Figs. 5, 6, 7, 8, 16, 17, and 23). 



CHAPTER III. 
PERCUSSION IN HEALTH. 

Percussion with the fingers or with a percussor and pleximeter 
— The normal vesicular resonance on percussion; its distinc- 
tive characters relating to intensity, pitch, and quality — 
Variations in the characters of the normal vesicular resonance 
in different persons — Relations of the pitch of resonance to the 
vesicular quality — Tympanitic resonance over the abdomen — 
Variations of the normal resonance in the different regions of 
the chest — Enumeration of the regions in which the resonance 
on the two sides varies, and those in which it is identical in health 
— Influence of age on the normal resonance — Influence of the 
acts of respiration on the resonance — Rules in the practice of 
percussion. 

Percussion may be performed with either the fingers 
or artificial instruments. The fingers suffice for the 
study and in ordinary practice. Instruments are 
preferable only when it is desired to produce sounds 
to be heard at a distance, as in class illustrations, and 
when, from the number of patients to be percussed, 
as in dispensary or hospital practice, the frequent 
repetition of the blows renders the fingers tender and 
painful. The instruments are a pleximeter and a 
percussor. A good form of a pleximeter, and of a 
percussion hammer are illustrated in Figs. 11 and 12. 

When percussion is performed with the finger the 



72 



PERCUSSION IN HEALTH 



palmar surface of one of those of the left hand should 
be applied to the chest, with pressure sufficient to 
condense the soft structures, and the blows are given 
with one or more of the fingers of the right hand bent 
at the second phalangeal joint so as to form a right 
angle. In giving the blows the movements should 
be limited to the wrist-joint, the ends, not the pulp 
of the percussing fingers, being brought into contact 




Fig. 11. — Pleximeter. 




Fig. 12. — Percussion hammer. 



with the dorsal surface of the finger applied to the 
chest. The percussing fingers should be withdrawn 
instantly the blow is given. The type of perfect per- 
cussion is the movement of the hammers when the keys 
of a piano-forte are struck. The force of the percus- 
sion should never be sufficient to give pain to the 
patient; generally either light or moderately forcible 
blows suffice. The requisite tact in the performance 
of percussion is acquired by a little practice. 



PERCUSSION IN HEALTH 73 

In percussion for the outlines of viscera lying close 
to the chest wall, light application of the pleximeter 
fingers, and a light stroke with the percussion finger 
gives best results. 

In percussion for deeply situated margins of viscera 
or, for example, areas of consolidation or cavities, the 
pleximeter finger can with advantage be applied 
more firmly, and the percussion stroke be slightly 
more vigorous. 

The first object in the study of percussion is to 
become acquainted with the characters which are 
distinctive of the sound obtained thereby from the 
healthy chest. For this object the percussion may 
be made either in the infraclavicular region of either 
side, or in the infrascapular region, because the sound 
in these situations is louder than in other regions. Per- 
cussion being performed, a sound or resonance is 
produced. This sound or resonance is now to be anal- 
yzed with reference to the characters derived from inten- 
sity, pitch, and quality. What are these characters? 

The intensity will depend, other things being equal, 
on the force of the blow; the resonance is compar- 
atively feeble with a slight, and loud with a strong, 
percussion. Other circumstances affect the intensity 
irrespective of the force of the blow — namely, the 
volume of the lung, the elasticity of the costal cartil- 
ages, and the thickness of the soft parts which cover 
the chest. Owing to these circumstances the intensity 
oi the resonance is by no means similar, in the same 
situation, in all healthy persons. It is comparatively 



74 PERCUSSION IN HEALTH 

feeble in some and loud in others. There is nothing 
distinctive of this normal resonance to be derived 
from intensity, and we say, therefore, that the intensity 
is variable. 

What is the pitch of this normal resonance? The 
pitch of a sound is always relative; and, comparing 
this resonance with all the morbid signs obtained 
by percussion, it is lower in pitch. We say, there- 
fore, that the pitch of this normal resonance is low. 
The pitch, however, is found to vary in different 
healthy persons. 

What is the quality of this normal resonance? It 
has a quality which is peculiar to it. In this respect 
it is not identical with any sound produced otherwise 
than by percussion over healthy lung. The quality 
can only be appreciated by direct observation. The 
peculiar quality is due to the fact that the resonance 
is from air contained in inflated pulmonary vesicles 
(vide p. 28). This quality, which we call vesicular, 
is not equally marked in all healthy persons, being, as 
a rule, more marked in proportion to the intensity of 
the resonance. 

This vesicular quality, as just noted, is peculiar to 
the pulmonary resonance. An approximative repre- 
sentation of it is obtained by percussing either a 
sponge or a loaf of bread. The latter gives a closer 
imitation than the former. Each of these articles 
affords a resemblance to the vesicular quality of reso- 
nance, for the reason that it contains air in an infinite 
number of small spaces separated by elastic walls, in 



PERCUSSION IN HEALTH 75 

this regard resembling the lungs. In order to represent 
this sign by percussing a loaf of bread, the loaf should 
be covered with a napkin, in order to lessen the noise 
produced by the contact of the finger or the percussor. 
The upper crust stands in place of the thoracic wall. 
The resonance elicited illustrates the lowness of pitch 
with a pretty close approach to the peculiar quality 
of the normal vesicular resonance. 

The normal resonance, then, may be defined as: 
A resonance of variable intensity, low in pitch and 
having a peculiar quality called vesicular. It is also 
called the normal resonance, the normal pulmonary 
resonance, or the normal vesicular resonance. The 
last of those names is to be preferred. 

The normal vesicular resonance on percussion, as 
has been seen, is not uniform in all healthy persons; 
not only is its intensity variable, but it varies in pitch 
and in the amount of vesicular quality. The fact, 
however, occasions no embarrassment for this reason : 
we determine, in each case, that the resonance is nor- 
mal by a comparison of the two sides of the chest, 
percussing in corresponding situations on the two sides, 
and with the same force. There is no ideal standard 
of the normal vesicular resonance, but by comparing 
the two sides of the chest the standard of health 
proper to each person is obtained. The laws of 
disease are such that, for all practical purposes, the 
standard of health is in this way almost always 
available. Notwithstanding the variations w^ithin the 
range of health, the lowness of pitch and the vesicular 



76 PERCUSSION IN HEALTH 

quality are sufficiently distinctive of this normal sign 
as compared with the morbid signs. 

The pitch of the vesicular resonance and its vesic- 
ular quality are in a uniform relation to each other; 
that is, the conditions giving rise to the peculiar 
quality also render the pitch low; and, conversely, 
with diminution of the vesicular quality the pitch is 
relatively higher. This relation will usually be found 
to hold good in the resonance modified by disease as 
well as in health. 

The pitch and quality of the normal vesicular 
resonance may be readily illustrated by percussing 
successively over the chest and the abdomen. Over 
the latter a more musical resonance of drum-like 
quality is obtained which is called tympany; depend- 
ing upon the gas contained within the abdominal 
viscera. The pitch varies with the amount of gas 
present but is normally higher than that obtained 
over the lung. In all these situations, bringing the 
tympanitic in contrast with the normal vesicular 
resonance, the peculiar quality of the latter and its 
lowness of pitch are rendered apparent. 

Having studied the characters of the normal vesic- 
ular resonance, and become practically familiar 
with them by percussing different healthy persons, 
the student should study the variations which this 
resonance presents in the different regions of the 
chest {vide p. 62) until he thoroughly appreciates that 
the vesicular quality is independent of the intensity 
or loudness of the note. 



SCAPULAR REGION 77 

Supra- or Postclavicular Region. — The resonance 
here varies much in intensity in different persons. 
The vesicular quahty is most marked in the central 
portions. Toward the sternal extremity the resonance 
acquires a tympanitic quality from the proximity to 
the trachea; it becomes vesiculotympanitic. In the 
supraclavicular region resonance is to be found extend- 
ing from three-fourths to two inches above the upper 
border of the clavicle. 

Clavicular Region. — Near the sternum the resonance 
is somewhat tympanitic from the proximity to the 
trachea. At the central portion the vesicular quality 
is more or less marked, and the intensity is diminished 
at the acromial extremity. Throughout the note is 
slightly modified by having the osseous (tympanitic) 
note of the clavicle added to the resonance of the 
underlying organs. 

Infraclavicular Region. — The resonance in this region 
is more intense than elsewhere, except in the axillary 
and the infrascapular regions. The vesicular quality 
is combined with a tympanitic quality toward the 
sternum, the latter being derived from the primary 
and secondary bronchi. 

Scapular Region. — The resonance in this region is 
notably less intense than in the infraclavicular region, 
owing to the presence of the scapula and its muscles, 
though sufficient to be of value in the detection of 
abnormal conditions in this situation. In proportion 
as the intensity is less, the vesicular quality is less 
marked. In the suprascapular region resonance is to 



78 PERCUSSION IN HEALTH 

be found for a distance of two to three and a quarter 
inches along the upper border of the trapezius muscle, 
a distance which should normally be equal on the two 
sides. 

Interscapular Region. — The resonance in this region 
is weak in comparison with other regions, except the 
scapular, owing to the muscles which here cover the 
chest. Above the resonance is somewhat tympanitic 
from the relation to the trachea and bronchi. 

Mammary Region. — The right and the left mam- 
mary regions are to be studied with reference to differ- 
ences relating to the liver and the heart. On the right 
side, from the fourth rib downward, the resonance 
is diminished, because the dome or upper surface of 
the liver extends up to this height. This deep 
liver dulness is more readily appreciated with rather 
forcible percussion. At about the sixth rib in the 
midclavicular line is the lower border of the right lung, 
and pulmonary resonance is replaced by liver flatness. 
Between the third and fifth ribs on this side near the 
sternum the resonance is slightly diminished from the 
presence of a portion of the right auricle and ventricle. 

On the left side the resonance is diminished within the 
precordial space. This space extends vertically from 
the third rib to the fifth intercostal space; and hori- 
zontally from the sternum to a point at or a little 
within the midclavicular line. The resonance is 
greatly diminished within what is called the super- 
ficial cardiac space. This space is represented by 
a right-angled triangle, the right angle formed by the 



MAMMARY REGION 79 

median line and a horizontal line intersecting the 
point of apex-beat in the fifth intercostal space; an 
oblique line drawn from the centre of the sternum 
on a level with the fourth rib and the point of apex 
beat forms the hypotenuse of the right-angled tri- 
angle. This oblique line is, in fact, curved, not 
straight (mde Fig. 5, p. 62), the convexity looking to 
the left side. Practically, however, it is near enough 
to accuracy to consider it the hypotenuse of a right- 
angled triangle. Within this space the heart is in 
contact with the thoracic wall. The resonance 
obtained, therefore, does not come from lung tissue 
directly beneath the pleximeter finger, but from 
diffusion of the percussion vibrations laterally to 
adjacent lung. The percussion stroke is particularly 
well transmitted along the costal cartilages and ster- 
num. To determine the superficial cardiac area, the 
lightest possible stroke should therefore be employed, 
and even then only the outer portion is demonstrable, 
because over the sternum a bony note, but no flatness, 
is obtained. Without this space and within the pre- 
cordia the heart is covered with lung, and the reso- 
nance on percussion is less diminished. It is a useful 
exercise for the student to determine by percussion 
the diminution of the area of the superficial cardiac 
space during forced inspiration. 

Aside from the presence of the heart and the convex 
extremity of the liver, the resonance over the mam- 
mary is less than in the infraclavicular region, being 
diminished by the pectoral muscle, which varies con- 



80 PERCUSSION IN HEALTH 

siderably in bulk in different persons; and, in women, 
by the mammary gland which, however, is never so 
great as to preclude the useful employment of per- 
cussion in this region. 

Inframammary Region. — In this region, as in the 
region above it, the two sides present notable differ- 
ences. On the right side, over the greater part, and 
sometimes the whole of this region, resonance is 
wanting, that is, percussion gives flatness, because 
no air-containing organ is present. It is easy to 
delineate the boundary between the lower border 
of the right lung and the liver, or, as it is called, the 
line of hepatic flatness. It is also easy to distinguish 
above this line the height to which dulness, due to the 
dome of the liver extends, or, as it is called, the line 
of hepatic dulness. This line does not correspond to 
the actual height of the liver dome, as was supposed 
before the days of x-yslj examinations. On the other 
hand, it is of some diagnostic value; because, with a 
progressive enlargement of the liver dome, the height 
of the liver dulness increases. The distance between 
the two lines is from one to two inches. Both lines 
are affected considerably by a forced inspiration and 
a forced expiration. A forced inspiration depresses 
the line of flatness about one and one-half inch. A 
forced expiration causes the line to rise from two 
and one-half to five and one-half inches. The dis- 
tance, therefore, between this line at the end of a 
forced expiration and at the end of a forced inspira- 
tion varies from four to seven inches. Not infrequently 



INFRAMAMMARY REGION 81 

percussion over the right inframammary region yields 
a tympanitic resonance due to the distention with 
gas of the transverse colon. 

On the left side the resonance in this region varies 
in different persons, in the same persons at different 
times, and in different portions of the region at the 
same time depending chiefly upon the air content of 
the stomach. Flatness is caused by the extension of 
the left lobe of the liver into this region about three 
inches to the left of the median line. 

The left portion of the region is in relation to the 
spleen, an organ which varies considerably in sizfe 
in health as well as in disease, its average dimensions 
being about four inches in length and three inches in 
width. 

The space corresponding to the spleen is determined 
by the vesicular resonance above and the tympanitic 
resonance in front and below; the latter boundary, 
however, not being very reliable on account of the 
ready conduction of tympanitic resonance for a certain 
distance. The spleen lies in the left hypochrondrium 
between the ninth and eleventh ribs, its long axis cor- 
responding to the tenth rib. Its posterior extremity 
is about one and one-half inches from the spinal 
column; its anterior pole reaches to the middle or at 
most to the anterior axillary line. The upper pos- 
terior third, being covered by lung, is inaccessible to 
percussion. The remainder, lying against the chest 
wall, unless forced away by intervening intestines, is 
found to give a dulness on examination in sitting, 
6 



82 PERCUSSION IN HEALTH 

standing, or the right-lateral recumbent position. 
The lung border, intersecting the eighth and ninth 
ribs, is the upper limit of splenic dulness; the anterior 
limit is rarely as far forward as the anterior axillary 
line; the lower limit is at the eleventh rib; posteriorly 
the dulness merges into that of the lumbar muscles. 

Between the spleen and the liver lies the stomach, the 
volume of which is constantly fluctuating according 
to its varying content of solid, liquid, or gas. 

A moderate amount of gas is almost invariably 
present; sufficient, in the recumbent posture at least, 
to give tympanitic resonance to the area in which the 
stomach is in contact with the thoracic wall — that 
half-moon-shaped space between costal arch and lower 
border of the lung, limited in front by the liver and 
behind by the spleen, called Trauhe's semilunar 
space. This space is of considerable importance in 
the diagnosis of left-sided pleural exudates, which 
by inserting a layer of fluid in the complemental 
pleural space, between the stomach and chest wall, 
decrease or abolish the normal tympany. 

Distention of the stomach with gas occasions a 
tympanitic resonance which is frequently transmitted 
high into mammary and axillary regions; so high, 
indeed, that it is occasionally mistaken for pneumo- 
thorax 

The distention of the stomach with solid or liquid 
contents, of course, occasions flatness. The study 
of the inframammary regions with reference to the 
variations in resonance arising from the organs below 



STERNAL REGIONS 83 

the diaphragm is of much utiHty from the practice 
which it involves, and will be of great service to 
the student in acquiring tact in percussion, and in 
discriminating differences in the sounds obtained by 
this method. 

Sternal Regions. — In the upper sternal region, that 
is, above the lower margin of the second rib, the 
resonance is non-vesicular, being derived from the 
sternum itself and also from air in the trachea. Being 
non-vesicular, it is, of course, tympanitic, inasmuch 
as the resonance is always tympanitic in quality if 
wholly devoid of the vesicular quality. 

Between the second and third ribs, the inner borders 
of the two lungs approximating, the resonance has a 
vesicular quality more or less marked; but owing to 
the remnant of the thymus gland, together with 
adipose substance, and the presence of the large 
vessels, the resonance is not intense in this situation. 

Below the third rib the resonance has modifications, 
due to the combination of several different organs 
situated beneath the lower sternal region. On the 
right side of the mesial line is the inner border of 
the right lung, the greater part of the right auricle 
and part of the ventricle of the heart lying beneath; 
a portion of the liver extends into the lower part 
of this region, and a portion of the stomach when 
distended. The resonance thus varies in different 
situations, and often presents a mixed character. 

The bone of the sternum has a characteristic note 
of its own which modifies all percussion sounds 



84 PERCUSSION IN HEALTH 

obtained upon it, whether there be resonance or 
extreme duhiess. 

Infrascapular Regions. — The resonance below the 
scapula is intense as compared with that over the 
scapula, and the vesicular quality is marked. The 
resonance extends to the tenth rib, which is the 
lower boundary of the lung. At or near this point, 
on the right side, is the line of hepatic flatness, hepatic 
dulness extending from one to two inches above this 
line. The line of hepatic flatness and of hepatic 
dulness is lowered from one to two inches by a deep 
inspiration, and raised by a forced expiration. On 
the left side the resonance may receive a tympanitic 
quality from the presence of gas in the stomach. 

Lateral Regions. — In these regions the resonance 
is relatively intense and notably vesicular. On the 
right side the line of hepatic flatness is at the eighth 
rib, hepatic dulness extending one or two inches above 
this line. On the left side the resonance may be 
rendered somewhat dull by the presence of the spleen, 
but it often has a tympanitic quality from the presence 
of gas in the stomach. 

The Lower Limits of the Lungs. — Allowing for marked 
individual variations, the average lower limit of 
pulmonary resonance lies on the right side in the lateral 
sternal line at the fifth and sixth rib, in the mid- 
clavicular line at the sixth intercostal space, in the 
midaxillary line at the lower margin of the seventh 
or upper margin of the eighth rib, in the scapular 
line at the ninth or tenth rib, near the vertebral column 



RECOGNITION OF NORMAL RESONANCE 85 

at the level of the eleventh thoracic spine. On the 
left side the lower limit runs outward from the mid- 
sternum behind the fourth rib to the parasternal line, 
then curving downward to reach the lower border of 
the sixth rib at the midclavicular line. From that 
point it turns outward and corresponds to the border 
on the right. 

Standards for the Recognition of Normal Resonance. — 
As has been stated, the normal vesicular resonance 
is not in all persons identical as regards intensity, 
pitch, and quality. There is, therefore, no fixed 
standard by which we can determine whether the 
resonance be normal or not. The standard proper to 
each person is to be ascertained by a comparison of 
the two sides of the chest; each person, in other words, 
furnishes his own standard of health. 

But all the regions do not normally correspond in 
respect to the resonance on the two sides. In the 
following regions the resonance is notably dissimilar 
on the two sides: The mammary, the inframammary, 
the infra-axillary, and the infrascapular. There is 
less disparity in the resonance on the two sides in the 
following regions: The supraclavicular, clavicular, 
and infraclavicular, the scapular and interscapular, 
and the axillary. In some of these regions, however, 
the resonance differs, and it is of practical importance 
to note the dissimilarity which thus belongs to health. 
This statement applies especially to the infraclavicular 
region, a region of great importance with reference to 
the signs of phthisis. In this region the resonance is 



86 PERCUSSION IN HEALTH 

less intense, less vesicular, and higher on the right side. 
The student should become practically familiar with 
the normal differences between the two sides. 

The normal resonance is affected by age. In early 
life, when the costal cartilages are flexible and elastic, 
the resonance is more intense and lower in pitch than 
in old age, when the cartilages are rigid and the vesic- 
ular structure of the lung more or less atrophied. 

The ribs and cartilages also effect percussion reso- 
nance, depending upon their degree of curvature. The 
greater the curvature, the more resistance is offered to 
the percussion stroke, just as the small end of an egg 
is stronger than the larger. Hence, in the case of a 
flattened chest, the note in the axilla is less resonant 
than that obtained in front, even though the lung be 
normal. This effect of the thoracic wall must be 
remembered, particularly in the examination of 
deformed chests, where dulness discovered over a 
sharply convex area must be decidedly discounted 
before considering it as proof of pathological change in 
the lung beneath. 

The resonance varies considerably in the different 
regions at the end of a full inspiration, and at the 
end of a forced expiration. With regard to this dis- 
parity, the following is an extract from a work on 
physical exploration, published by the author in 1856: 

''The percussion sound may also be found to vary 
at different periods of an act of respiration in the 
same individual. The quantity of air contained 
within the air cells, and consequently the relative 



RECOGNITION OF NORMAL RESONANCE 87 

proportion of air and solids, are by no means equal 
after a full inspiration and after a forced expiration. 
The difference in lung expansion may occasion an 
appreciable disparity in resonance, according as the 
I>ercussion is made at the conclusion of a full inspira- 
tion or of a forced expiration. The disparity is not 
appreciable uniformly in different persons. When 
it does exist, it usually consists, contrary to what 
might perhaps have been anticipated, and the reverse 
of what is usually stated in works on physical explora- 
tion, in diminished resonance and elevation of pitch 
at the conclusion of inspiration. This is probably 
to be explained by the greater degree of tension of 
the lungs and thoracic walls produced by inspiration 
voluntarily prolonged and maintained — a condition 
presenting physical obstacles to sonorous vibrations 
more than sufficient to counterbalance the increased 
proportion of air within the cells (vide p. 27). It is 
a curious fact, worthy of notice, that the two sides 
of the chest are not always found to be affected equally 
as regards the percussion sound at the conclusion of 
a full inspiration, contrasted with that after a forced 
expiration. I have observed the contrast to be more 
striking on the right than on the left side; and in one 
instance on the left side the resonance was less intense 
and somewhat tympanitic after a full inspiration, 
while on the right side the opposite effect was pro- 
duced and the sound became quite dull after a forced 
expiration. In view of these variations in a certain 
proportion of instances incident to different periods of 



88 PERCUSSION IN HEALTH 

a single act of respiration, in some cases of disease in 
which it is desirable to observe great delicacy in the 
correspondence of the two sides, pains should be taken 
to percuss corresponding points at a similar stage 
of respiration; and the close of a full inspiration is, 
perhaps, the period to be preferred. Ordinarily, the 
liability to error from this source is obviated, either 
by repeating a series of strokes, first on one side and 
next on the other; or by percussing both sides repeat- 
edly in quick succession, in order mentally to obtain 
the average intensity and other characters of the 
sound during the successive stages of a respiration. 
The instances of disease, however, are exceedingly rare 
in which such nicety of discrimination is important." 
There are two variations in methods of percussion 
which are found to assist in determining the boun- 
daries of solid viscera and cavities: (a) The so-called 
auscultatory percussion, which consists in applying 
the stethoscope over an area to be outlined, as over 
the precordium, and then by light percussion (or even 
delicately stroking or scratching the skin), approach- 
ing the stethoscope from all directions, noting the 
sudden change in intensity of the conducted sound 
as the border of the underlying viscus is reached. 
This method is of service also in outlinmg the borders 
of the stomach, (b) The so-called threshold percussion 
of Goldscheider, which consists in light percussion 
upon the second phalangeal joint of the bent plex- 
imeter finger, the tip only of the finger being applied 
to the chest. By using only the interspaces and also 



RULES IN THE PRACTICE OF PERCUSSION 89 

limiting as finely as this the point of application of the 
stroke, often very precise limits of the heart may be 
determined. 



RULES IN THE PRACTICE OF PERCUSSION. 

1. Prior to a comparison of the two sides of the 
chest, as regards the resonance on percussion, an 
examination by inspection should be made, in order 
to determine whether there be any deviation from the 
normal conformation. In what has been stated, it is 
assumed that the chest is symmetrical. Any deviation 
from the normal conformation will affect more or 
less the resonance in corresponding regions on the two 
sides {vide p. 86). Due allowance is to be made for 
want of symmetry in determining morbid signs, and 
often the existence of these cannot be determined with 
positiveness when there is considerable deformity. 
The signs obtained by auscultation are less affected by 
want of symmetry than those obtained by percussion. 

2. The position of the person examined is impor- 
tant with reference to the normal symmetry of the 
chest. If the person be standing or sitting, the posi- 
tion should be upright and the shoulders brought 
to a level. A little inclination of the body to one 
side, or a depression of one shoulder, will be found 
to affect perceptibly the normal resonance when the 
two sides are compared. If the body be recumbent, 
it should be as nearly as possible on a level plane. 
With a patient in the lateral recumbent position, the 



90 PERCUSSION IN HEALTH 

side which is uppermost should be examined and the 
patient then turned to the other side. Otherwise the 
percussion note of the lower side is modified, not only 
because of the asymmetry of the chest, but also by 
resonance contributed from the mattress; so that a 
reliable comparison between the two sides cannot be 
made. 

3. The person who percusses should be, as nearly as 
possible, either in front or behind the person per- 
cussed. Percussion made by one standing, or sitting, 
by the side of the person percussed is almost certain 
to produce disparity in resonance. 

4. Percussion made successively on one side and 
the other side, must be in all respects the same in 
regard to the force of the blow, the firmness with which 
the pleximeter finger is applied, and the situation. 
A light percussion on one side and a strong percus- 
sion on the other side will, of course, cause a disparity 
in the intensity of resonance. The percussion must 
be made in succession at points as nearly as possible 
equidistant from the median line, and from the sum- 
mit or base of the chest. With reference to great 
nicety, the percussion, if made on the rib or inter- 
costal space on one side, must be made on the rib or 
intercostal space on the other side. Great nicety also 
requires that if the percussion be made on one side 
during the act of inspiration, it should be made on the 
other side during this act. The signs of disease, how- 
ever, are generally so well marked that very close 
attention to these points is not necessary. 



RULES IN THE PRACTICE OF PERCUSSION 91 

5. A series of blows in rapid succession (four or five) 
is to be preferred to one or two, in practising percus- 
sion; difference in intensity, pitch, and quality being 
thereby better appreciated. For most purposes, however, 
two or three strokes are sufficient from the stand-point 
of the examiner, and are much preferred by the patient. 

6. Percussion may be made lightly or forcibly, the 
former being called superficial, and the latter, deep 
percussion (vide p. 29). With light blows the reso- 
nance comes from the superficies of the lung and from 
within a limited area. With forcible blow^s the reso- 
nance is from a greater depth and a wider space. The 
result of these different modes of practising percussion 
may be illustrated within the precordia in health. 
Comparing the resonance over the superficial cardiac 
space with that in a corresponding situation on the 
right side, dulness is more marked with light than with 
forcible blows, the resonance from the latter coming 
from a wider area. On the other hand, comparing 
the resonance over the deep cardiac space, dulness 
is more marked with forcible than with light blows, 
owing to the presence of lung between the heart and 
the walls of the chest. 

7. Percussion over the anterior portion of the 
chest, the person percussed leaning against a door, a 
board partition, or a lathed wall, gives an increased 
intensity of resonance. It is often useful to resort to 
this procedure in the practice of percussion. 

This very intensity of resonance may lead to error 
if the patient is examined while lying on a couch which 



92 PERCUSSION IN HEALTH 

is equipped with a box-spring. Ignorance of, or inat- 
tention to, the resonating cavity beneath the patient 
may cause confusion in interpreting the signs of 
percussion. 

8. In percussing over the posterior portion of the 
chest it is important that the scapulae be drawn for- 
ward and downward. By having the patient cross 
the arms upon the chest, the hands being placed 
upon the tips of the shoulders and then drawing 
the shoulders down and bending the head well down 
upon the chest, the greatest area of the posterior 
thorax is exposed to examination. Thus- the supra- 
scapular and interscapular regions become artificially 
increased to the great convenience of the examiner. 
The above procedure is of value when the patient is 
standing or sitting up in bed. The degree of bending 
should not be sufficient to materially tighten the 
muscles, as in that case the chest wall becomes more 
resistant to the transmission of vibrations. 

A position which gives the maximum of muscular 
relaxation and the greatest exposure of the upper lobes 
behind may be assumed by the patient while seated 
on a stool: the body is bent well forward, the head 
hanging downward and forward upon the chest, and 
the arms hanging down loosely outside the thighs. 



CHAPTER IV. 
PERCUSSION IN DISEASE. 

Enumeration of the signs of disease furnished by percussion 
— Requirements for a practical knowledge of these signs — The 
distinctive characters of the morbid physical conditions repre- 
sented by, and the different diseases into the diagnosis of which 
enter the signs, severally, to wit: 1. Absence of resonance or 
flatness 2. Diminished resonance. 3. Tympanitic resonance. 
4. Vesiculotympanitic resonance. 5. Amphoric resonance. 6. 
Cracked-metal resonance. 7. Unusual changes of tone — Sense 
of resistance felt in the practice of percussion as a morbid sign. 

Percussion in cases of disease furnishes signs 
which represent the changed physical conditions inci- 
dent to the affections; with these physical conditions 
and their relations to pulmonary affections the student 
is supposed to be familiar {vide p. 47 et seq.). 

The signs of disease furnished by percussion are 
resolvable into six, namely: (1) Absence of resonance 
or flatness; (2) diminished resonance or dulness; 
(3) tympanitic resonance; (4) vesiculotympanitic reso- 
nance; (5) amphoric resonance; (6) cracked-metal reso- 
nance. The last two named signs are varieties of 
tympanitic resonance, but it is most convenient to 
consider them as distinct signs. 

Knowledge of these six signs in physical diagnosis 
requires: (1) A practical acquaintance with the char- 



I 



94 PERCUSSION IN DISEASE 

acters which distinguish each from the others, as 
well as from the normal resonance; and (2) a clear 
apprehension of the significance of each. That is, 
we must be able to recognize the signs, on the one 
hand; and on the other hand, we must be able to inter- 
pret them into terms of the physical changes which 
they represent. 

ABSENCE OF RESONANCE OR FLATNESS. 

This sign is sufficiently defined by its name. It 
is absence of resonance or tone. Nothing is heard 
but the noise of percussion finger striking the plex- 
imeter, such as may be produced by percussing over a 
solid mass, for example, a limb composed of muscle 
and bone, or over a collection of liquid, for example, 
the abdomen in ascites. There being no resonance or 
tone, the sign has no characters pertaining to pitch or 
quality. It may be illustrated on the healthy chest 
by percussing in the. right inframammary region below 
the line of hepatic flatness. 

Absence of resonance on percussion over the lungs 
means simply absence of air in the tissue beneath. This 
flatness on percussion occurs under four main morbid 
conditions, namely: (1) The presence of liquid either 
in the pleural sac or in pulmonary cavities; (2) liquid 
filling the air vesicles; (3) complete solidification of 
lung; and (4) a tumor within the chest. 

Flatness on percussion always represents one of 
these morbid physical conditions. Extreme thick- 



ABSENCE OF RESONANCE OR FLATNESS 95 

ening of the visceral and parietal pleura at the base of 
the lung may give a note so nearly flat that a differ- 
ential diagnosis cannot be made between thickened 
pleura and hydrothorax without the use of an explor- 
ing needle. 

These conditions are incident to different diseases, 
as follows: 

1. Liquid in the pleural cavity is incident to 
pleurisy with effusion, empyema, and hydrothorax. 
A collection of pu5 constitutes pulmonary abscess; 
and phthisical cavities, or those caused by circum- 
scribed gangrene, may become filled with morbid 
liquid products. 

2. Serous effusion into the air vesicles constitutes 
pulmonary edema. Liquid blood extra vasated char- 
acterizes hemorrhagic infarctus, pneumorrhagia, or 
pulmonary apoplexy. Pus infiltrating more or less 
of the parenchyma may be derived from an abscess 
either within the lung or elsewhere, for example, the 
liver, and from the pleural cavity in empyema when 
perforation of lung takes place. 

3. Solidification of lung occurs in pneumonia from 
an exudation within the air cells; it is produced by 
condensation from compression by liquid or air in the 
pleural sac, the pressure of a tumor, and by collapse; 
it exists in cases of phthisis, in interstitial pneumonia, 
and in neoplastic infiltration of lung. 

4. Tumors within the chest are of different kinds, 
for example, aneurisms, primary and secondary neo- 
plasms, echinococcus cysts, and teratomata. In pro- 



96 PERCUSSION IN DISEASE 

portion to their size they occupy space belonging to 
the lung, as well as condensing the latter by pressure. 
Flatness may also be caused by the encroachment of 
organs situated below the diaphragm upon the thoracic 
space, as in cases of enlargement of the liver and spleen, 
and in massive ascites. 

Flatness on percussion in all these conditions is the 
same. The sign alone does not enable us to discrimi- 
nate the conditions from each other, nor to determine 
the existing disease. 

Finding this sign present, the particular condition 
and the disease in each case are to be determined by 
the situation of the flatness, its extent, the associated 
physical signs furnished by auscultation, together 
with the other methods of exploration, and by the 
symptomatic phenomena. 

DIMINISHED RESONANCE OR DULNESS. 

The resonance on percussion is diminished, or 
there is dulness, when the solids or liquids within 
the chest are morbidly increased without increase in 
the quantity of air, the increased amount of solids or 
liquids not being sufficient to cause flatness. Dimi- 
nution of air without increase of either solids or 
liquids, as in collapse of pulmonary lobules, also 
gives rise to dulness. In other w^ords, dulness occurs 
in the presence of an abnormal proportion of solids 
or liquids over the air in the pulmonar}^ vesicles. 

Dulness varies in degree. It may be slight, mod- 



DIMINISHED RESONANCE OR DULNESS 97 

erate, considerable, or great. The degree of dulness 
corresponds to the amount of the relative dispropor- 
tion of solids or liquids over the air within the chest. 

The pitch of sound is higher than that of the normal 
resonance of the persons percussed. This is invariable; 
with dulness there is always more or less elevation of 
pitch. The quality is altered only in amount; there 
is, of course, less vesicular quality in proportion as 
the intensity of the resonance is diminished. 

The characters which distinguish this sign, thus, 
are lessened intensity of resonance, elevation of 
pitch, and weakened vesicular quality. 

The morbid conditions giving rise to this sign are 
those which, existing in a greater degree, give rise 
to flatness. Morbid products within the pleural sac, 
fibrin, serum, pus, lymph, if not sufficient to cause 
flatness, give rise to dulness. The sign, therefore, 
occurs in pleurisy, empyema, and hydrothorax. The 
same is true of pulmonary edema, hemorrhagic infarc- 
tus, pneumorrhagia, and purulent infiltration of lung. 
Solidification of lung, when not complete, occasions 
dulness; hence, it is a sign in pneumonia, vesicular 
and interstitial, in phthisis, in condensation of lung 
from compression, in collapse of pulmonary lobules, 
and in neoplastic infiltration. A tumor within the 
chest, not sufficiently large to cause flatness, gives 
rise to dulness. 

There are, however, some conditions giving rise to 
dulness which are never sufficient to cause flatness. 
Pulmonary congestion limited to a lobe may diminish 
7 



98 PERCUSSION IN DISEASE 

the resonance appreciably. The dulness may exist 
in the first stage of pneunionia, before soHdification 
from pneumonic exudation has taken place. A layer 
of fibrin upon the pleural surfaces causes dulness 
after the liquid effusion in pleurisy has been removed, 
and after the vesicular exudation in pneumonia is 
absorbed. Dulness may also be caused by a consider- 
able accumulation of mucus or coagulated blood 
within the intrapulmonary bronchial tubes. 

The particular morbid condition which gives rise 
to dulness cannot be inferred from the characters of 
j the sign: the sign only denotes that some one of them 

exists. The condition which exists in each case, and 
the disease, are to be determined by the situation, 
extent, and degree of dulness, taken in connection with 
the information derived from other methods of explora- 
tion than percussion, together with the history and 
symptoms. 

TYMPANITIC RESONANCE. 

Resonance is tympanitic whenever it is entirely 
devoid of the vesicular quality; in other words, any 
resonance which is non-vesicular is tympanitic. The 
leading distinctive character of the preceding sign 
(dulness) relates to intensity, whereas the leading 
distinctive character of this sign relates to quality. 
Tympanitic resonance derives no distinctive char- 
acter from intensity; it may be either more or less 
intense than the resonance of health in the person 



TYMPANITIC RESONANCE 99 

percussed. This point is to be emphasized, inasmuch 
as with many the idea of tympanitic resonance involves 
increased intensity of sound; a resonance, be it ever 
so feeble, if it be non-vesicular, is tympanitic. If, 
however, the resonance be quite feeble, it is not 
always-eas;^^to determine whether there be, or not, any 
appreciable vesicular quality. The term used by 
Stokes, namely, "tympanitic dulness," is properly 
enough applied to a resonance with diminished inten- 
sity, in which a vesicular quality cannot be appreciated. 
As regards pitch, a tympanitic resonance is usually 
higher than the normal vesicular resonance. The ex- 
ceptions to this rule are extremely infrequent. The 
tympanitic resonance over different parts of the abdo- 
men is always higher in pitch than the resonance 
over healthy lung. 

The following are the morbid physical conditions 
which give rise to the tympanitic resonance : 

1. Air in the pleural cavity. It is, therefore, a 
sign of pneumothorax. Frequently in this affection 
the tympanitic resonance is more intense than the 
resonance of health, the pitch being almost always 
more or less raised. 

2. Pulmonary cavities containing air. It occurs, 
therefore, in cases of phthisis. In this disease the 
tympanitic resonance is limited to a circumscribed 
space corresponding to the site and size of the cavity; 
whereas in pneumothorax it frequently exists over 
a considerable part, or the whole, of the affected side 
of the chest. 



100 PERCUSSION IN DISEASE 

3. Complete solidification of the whole or a part 
of the upper lobe of lung. The tympanitic reso- 
nance under these circumstances is derived from the 
air in the lower part of the trachea and the bronchial 
tubes exterior to the lungs. This is the explanation 
of the sign in the second stage of pneumonia affecting 
an upper lobe, and in certain cases of phthisis prior 
to the stage of excavation. Dilatation of the intra- 
pulmonary bronchial tubes, with solidification sur- 
rounding them, as in some cases of interstitial pneu- 
monia or cirrhosis of lung, may give rise to tympanitic 
resonance. 

4. Conduction of resonance from the stomach or 
colon containing air or gas. A gastric tympanitic 
resonance is frequently conducted over a part, and 
sometimes over the whole, of the left side of the chest. 
This is more likely to occur when the left lung is 
solidified. On the right side less frequently a tym- 
panitic resonance may be conducted upward from 
the colon to a greater or less extent. 

Tympanitic resonance may be illustrated by per- 
cussion over the hollow abdominal viscera, provided 
they contain air or gas. The sign may be imitated by 
percussing an inflated hot-water bottle, or India-rubber 
balls. The pitch will be found to vary according to 
the size and the degree of inflation of the bladder or 
balls. To illustrate this resonance in proximity to a 
vesicular resonance, one-half of the soft portion of an 
oblong loaf of bread may be removed, leaving intact 



VESICULOTYMPANITIC RESONANCE 101 

the upper crust. Percussion over this half of the loaf 
illustrates the tympanitic, and over the other half the 
vesicular resonance. 

VESICULOTYMPANITIC RESONANCE. 

This name was proposed by the author many years 
ago to denote a sign with the following distinctive 
characters: The resonance is increased in intensity; the 
quality a combination of the vesicular with a tympan- 
itic, and the pitch high in proportion as the tympanitic 
quality predominates over the vesicular. 

The sign represents especially one morbid physical 
alveolar condition, namely, a lessened tension of the 
elastic alveolar fibers, which permits the lung tissue to 
vibrate in" union with the air content (vide p. 28). 

A vesiculotympanitic note is obtained over pul- 
monary emphysema because the parenchyma has 
gradually lost its tension by stretching. It is also, 
as a rule, present when the lung is relaxed by accumu- 
lations of fluid beneath, provided the latter is sufficient 
to fill one-third, one-half, or even two-thirds of the 
intrathoracic .space. A chest filled with fluid, on the 
other hand, renders the lung atelectatic and causes 
flatness on percussion. 

The sign is also frequently obtained over the adjacent 
position of upper lobe when the lower lobe is solidified 
in the second stage of pneumonia, and over the lower 
lobe when the upper lobe is solidified. 

A loaf of bread may be used to illustrate a vesiculo- 



102 PERCUSSION IN DISEASE 

tympanitic resonance, as follows: By means of a 
hollow cylinder remove longitudinal sections in one- 
half of the loaf, leaving the crust intact. The spaces 
thus produced yield a tympanitic resonance, and the 
portions which surround these spaces give the vesicular 
resonance. The vesicular and the tympanitic quality 
are thus combined, with elevation of pitch and increased 
intensity; over the other half of the loaf the resonance 
is purely vesicular. Another method of illustrating 
this sign out of the body is to inflate the human lungs, 
or the lungs of the sheep or calf. Until the inflation 
has reached a point somewhat below that of normal 
lung the percussion note is tympanitic; then with 
increasing distention it changes to vesiculotympany ; 
and finally to vesicular resonance, when full normal 
distention is attained. 

AMPHORIC RESONANCE. 

Resonance is said to be amphoric (a subdivision of 
tympany) when it has a musical intonation analogous 
to that produced by blowing over the mouth of an 
empty bottle. An amphoric sound is easily illustrated 
by percussing the cheek made tense, the mouth not 
completely closed, and the jaws separated, as is done 
when the sound of a liquid flowing from a bottle is 
imitated. By varying the size of the cavity of the 
mouth the amphoric sound thus produced may be made 
to vary much in pitch. This illustration exemplifies 
the mechanism of the sign in disease. 



AMPHORIC RESONANCE 103 

The sign represents a pulmonary cavity which is 
generally phthisical. The conditions, aside from the 
existence of the cavity, are the presence, of course, 
of air within the cavity, and free communications 
with the bronchial tubes. These accessory condi- 
tions are not constant,, so that an amphoric resonance 
over a cavity is sometimes found, and at other times 
is wanting. Directly after having been wanting, it 
may be reproduced if the patient expectorates freely. 

When percussion is made with reference to this 
sign, the mouth of the patient should be open, and 
one or two rather forcible blows are better than a 
series of four or six. The amphoric sound may be 
often distinctly perceived if the ear be brought into 
close proximity to the patient's open mouth, when 
the sign is not appreciable otherwise. It may be 
rendered still more distinct by means of the binaural 
stethoscope, the pectoral extremity being close to the 
mouth of the patient. 

As a cavernous sign the amphoric resonance is 
very reliable; but it does not invariably denote a 
pulmonary cavity. It is obtained in some cases of 
pneumothorax, if the pleural space communicates freely 
with the bronchial tubes. It is sometimes obtained 
over a solidified portion of lung situated in close prox- 
imity to a primary bronchus, the resonance being 
derived from the air within the latter. It is occasion- 
ally produced by percussing over the site of the primary 
bronchus in the second stage of pneumonia affecting 
an upper lobe. In children, owing to the yielding 



104 PERCUSSION IN DISEASE 

of the costal cartilages, it may even be produced in 
health over a primary bronchus. In all these excep- 
tional instances the associated signs and symptoms 
will prevent the error of attributing the sign to a 
pulmonary cavity. 

This sign is properly a variety of tympanitic reso- 
nance. 

CRACKED-METAL RESONANCE. 

The name of this sign, expressing an analogy to 
the sound produced by striking a cracked metallic 
vessel, denotes its peculiar character. It may be 
imitated by folding the hands so as to form a cavity 
and striking them upon the knee, or by forcibly per- 
cussing a rubber hand bulb with a rather small open- 
ing. In both cases a composite sound is produced, 
consisting in the tympanitic note of the cavity to 
which is added a short hiss, as some of the air is forced 
out from between the palms or through the neck of 
the bulb. Like the sign last described, it is a variety 
of tympanitic resonance. 

The cracked-metal, like the amphoric, resonance 
represents generally a phthisical cavity. Percussion 
is to be made in the same w^ay as for the production 
of the amphoric resonance, and, like the latter, the 
cracked-metal character is often best perceived if 
the ear, or, better still, the stethoscope be brought 
close to the patient's mouth. 

The cracked-metal and the amphoric resonance 
are often associated; and the exceptional instances 



SENSE OF RESISTANCE 105 

already mentioned in which the latter is produced, 
without the existence of a pulmonary cavity, will 
apply equally to the former. 

THE WINTRICH, WILLIAMS, AND GERHARDT 
PHENOMENA. 

If a patient who exhibits a vesiculotympanitic note 
or tympany over a cavity communicating freely with a 
bronchus, opens his mouth during percussion the pitch 
of the note is raised. This is called Wintrich's change 
of pitch, or Wintrich's phenomenon. When this phe- 
nomenon occurs where there is infiltrated or contracted 
lung tissue but no cavity, it is called Williams's tracheal 
tone. This may be illustrated by percussion of the 
cheek or larynx with the lips alternately closed and 
opened. If the pitch of a tympanitic note over a 
cavity changes with the patient's position we speak 
of this change as Gerhardt's tone change or phenome- 
non. It indicates a change of the shape of the reso- 
nating chamber, owing to the shifting of fluid on change 
of position. 

SENSE OF RESISTANCE. 

In addition to the acoustic phenomena produced by 
percussion with the fingers applied to the chest instead 
of a pleximeter, an abnormal sense of resistance is felt 
in certain conditions of disease. In health, with a some- 
what forcible percussion, the walls of the chest are felt 
to yield in proportion as the costal cartilages are flexible. 



106 PERCUSSION IN DISEASE 

This yielding is diminished or ceases when a collection of 
liquid in the pleural cavity, or liquid in the air vesicles, 
and solidification of lung, offer a mechanical obstacle 
thereto. An abnormal sense of resistance on percussion, 
thus determinable by comparison of the two sides of the 
chest, is a sign representing some one of the morbid 
physical conditions just named. On the other hand, 
in pneumothorax one of the most suggestive signs, 
though incapable of demonstration to others, is the 
extraordinary springiness of the chest wall. The appre- 
ciation of resistance comes only after practice, but 
when acquired is of very real assistance. This properly 
belongs among the signs obtained by palpation. 



CHAPTER V. 
AUSCULTATION IN HEALTH. 

Importance of the study of the auscultatory sounds in health 
— Immediate and mediate auscultation — Advantages of the 
binaural stethoscope — Rules to be observed in auscultation — 
Divisions of the study of auscultation in health — The normal 
laryngeal and tracheal respiration — The normal vesicular mur- 
mur; its distinctive characters, and the variations in the differ- 
ent regions on the same side, and in corresponding regions 
on the two sides of the chest — The normal vocal resonance — 
The laryngeal and tracheal voice and whisper — The normal 
thoracic vocal resonance and fremitus; the distinctive characters 
of each: the variations in different regions on the same side, and 
in corresponding regions on the two sides of the chest — The 
normal bronchial whisper, with its variations in different regions 
on the same side, and in corresponding regions on the two sides 
of the chest. 

The term auscultation, when dealing with the 
respiratory system, denotes the act of listening to 
the normal and abnormal sounds produced by respira- 
tion, voice, whisper, and cough. 

The study of auscultatory sounds in health is 
essential as preparatory for the study of auscultation 
in disease. The student must be familiar with the 
normal sounds before undertaking to become acquainted 
with those which represent morbid conditions. Ample 
time and attention should be given to the study of 
auscultation in health; until the student is familiar not 



108 AUSCULTATION IN HEALTH 

only with the sounds heard over a typically normal 
chest, but also with the rather wide variations of those 
sounds which are still consistent with normal lungs 
beneath. The omission to do this is a frequent cause 
of difficulty and want of success in attaining to a 
satisfactory proficiency in physical diagnosis. More- 
over, as will be seen, some of the most important of 
the morbid signs have their analogues in certain normal 
sounds pertaining to the respiratory system. 

Auscultation is either immediate or mediate. It 
is immediate tvhen the ear is applied directly to the 
chest, which may be either denuded or covered with 
a cloth or clothing. It is mediate when the sounds 
are conducted to the ear by means of an instrument 
called a stethoscope. The student should practice both 
immediate and mediate auscultation. The direct 
application of the ear to the chest suffices for diagnosis 
in many cases of disease ; but there are sometimes objec- 
tions to this by the patient on the score of delicacy, 
and by the auscultator on the score of the uncleanli- 
ness of the person examined. There are certain parts 
of the chest which can only be explored by the stetho- 
scope, and this instrument has the advantage of cir- 
cumscribing the space whence the auscultatory sounds 
are derived. Moreover, by means of the stethoscope, 
which is to be preferred over the great variety of 
instruments heretofore in use, the sounds are usually 
heard much better than by immediate auscultation. 
Immediate auscultation, however, is sometimes of 
the greatest value in the detection of very soft bronchial 



STETHOSCOPE 109 

breathing and in the recognition of certain faint 
high-pitched cardiac murmurs. It is also useful in 
appreciating the strength of the apex beat, or the 
pulsation over aneurisms, although this belongs 
properly to palpation. 

Stethoscope. — The stethoscope which is to be pre- 
ferred conducts the sounds into both ears, that is, it 
is binaural. In this consists its great superiority. An 
instrument must fit the individual examiner, or it is 
without value. The knobs which are to enter the ears 
must be of the right size; if they enter too far they 
occasion pain. The curves at the aural extremity 
must be such that the aperture is in the direction of 
the meatus of the ear. The flexible tubes must not 
be stiff, and their movements must be noiseless. All 
the tubes must be unobstructed, for it is the air within 
the tubes which conducts the sounds; and they must 
be sufficiently thick to exclude sounds arising outside 
the patient. In the use of the instrument it should be 
applied to the chest without any intervening clothing. 

The use of the binaural stethoscope is so universal 
and the types are, on the whole, so similar that it 
seems out of place in the present edition to discuss the 
matter in detail. The selection of the chest-piece, 
whether large or small, funnel or bell-shaped, is a matter 
for the individual physician to decide according to his 
need and use, merely noting, according to the shape of 
the bell, certain pitched sounds are better or more 
poorly heard. The flat chest-piece used in the Bowles 
phonendoscope is convenient in examining the posterior 



110 AUSCULTATION IN HEALTH 

regions of the chest, in patients so ill in bed that the 
chest cannot be made easily accessible in all its parts. ^ 

Rules for Auscultation. — ^The rules to be observed in 
the practice of auscultation, in health and disease, 
may be here introduced. 

In auscultation, as in percussion, corresponding 
situations on the two sides of the chest are to be 
explored successively, and compared. When the 
stethoscope is used, the pectoral extremity must be 
applied on each side with the same degree of pressure; 
this is especially essential in the comparison of vocal 
sounds. In immediate auscultation the ear is to 
be applied with a certain degree of force, and a thin 
layer of clothing does not interfere materially with 
the perception of auscultatory sounds. The ear 
not applied to the chest may or may not be closed 
by the finger in listening to the respiratory sounds; 
it should be closed in listening to the vocal sounds, 
in order to prevent confusion from attention to the 
voice from the patient's mouth. In immediate auscul- 
tation, whenever practised, the auscultator should 
take a position which will not interfere with the sense 
of hearing, and not occasion a feeling of discomfort. 
These difficulties are in the way of auscultating with 
the body bent forward; the sense of hearing is dulled 
by the detention of blood in the head, and the position 

1 The makes of stethoscopes provided by Tiemann and Ford, 
in New York, and the Gannett model, formerly used largely in 
Boston and Baltimore, are reliable. The Bowles phonendoscope 
is made by Pilling & Sons, of Philadelphia. 



RULES FOR AUSCULTATION 111 

cannot be maintained without discomfort. The per- 
son examined, if practicable, should be sitting, and 
the position for the auscultator is that of kneeling 
on one knee, and lowering, if necessary, the body, 
so that the head may be kept upright. These points 
are less important if the binaural stethoscope be used. 

When listening to respiratory sounds, it is gener- 
erally desirable that the person examined should 
breathe with somewhat greater force than in ordinary 
breathing; but it is important that the normal rhythm 
of respiration should be unchanged. Persons when 
requested to breathe with increased force are apt to 
err in breathing violently, and frequently with con- 
siderable noise produced in the nose or mouth. The 
readiest mode of obtaining what is desired, is for the 
examiner to illustrate it by his own breathing. A 
complete expiration is important in order to secure a 
satisfactory inspiration. It should therefore be made 
clear by explanation and illustration that each expira- 
tion should be finished before the following inspiration. 

The ability to abstract the mind from thoughts 
and sounds other than those to which the attention 
is to be directed, is essential to success in ausculta- 
tion. All persons do not possess equally this ability, 
and herein is an explanation in part of the fact that 
all are not alike successful. To develop and cultivate 
by practice the power of concentration is an object 
which the student should keep in view. Generally, 
at first, complete stillness in the room is indispensable 
for the study of auscultatory sounds; with practice, 



112 AUSCULTATION IN HEALTH 

however, in concentrating the attention, this becomes 
less and less essential. 

The study of auscultation in health embraces the 
following : 

1. The sounds produced by respiration as heard 
over the larynx and trachea, or the normal laryngeal 
and tracheal respiration. 

2. The sounds heard over the chest in the acts 
of respiration. These sounds, coming chiefly from the 
air vesicles, constitute what is called the normal 
vesicular murmur. 

3. The resonance heard over the chest, and the 
vibration or thrill produced by the loud voice, or the 
normal weal resonance and fremitus. 

4:. The sounds heard over the chest with the whis- 
pered voice, or, inasmuch as these sounds are con- 
ducted chiefly by the air in the bronchial tubes, the 
normal (bronchial) whisper. 

These four normal signs will be considered in the 
foregoing order. 

NORMAL LARYNGEAL AND TRACHEAL 
RESPIRATION. 

For all practical purposes the laryngeal and the 
tracheal respiration may be considered to be iden- 
tical, that is, the shades of difference between the 
sounds in these two situations are not of importance 
as regards the application to physical diagnosis. The 
laryngeal respiration is more readily studied than the 



LARYNGEAL AND TRACHEAL RESPIRATION 113 

tracheal, and for the study of each the stethoscope is 
necessary. 

Applying the stethoscope over the side of the larynx, 
the person examined breathing with some increase of 
force, but without any alteration in rhythm, a sound 
is heard with each of the two acts of respiration. 
The inspiratory and the expiratory sound, studied 
separately and contrasted with each other, have 
the following characters relating to intensity, pitch, 
quality, duration, and rhythm: The inspiratory 
sound is of variable intensity. In ordinary breathing 
it varies much in different persons, and in different 
acts of breathing in the same person. It is always 
intensified in forced breathing. The pitch is high 
when compared with the inspiratory sound as heard 
over the chest. The quality of the sound is well 
defined by the word tubular; the sound at once sug- 
gests a current of air through a tube. The duration 
of the sound is from the beginning to nearly, not 
quite, the end of the inspiratory act. The characters 
of the inspiratory sound, thus, are more or less inten- 
sity, a high pitch, a tubular quality, and a duration 
a little less than that of the act of inspiration. 

An expiratory sound is always heard with forced 
breathing. As regards duration, it is as long as, or 
longer than, the sound of inspiration. In general it 
is more intense than the sound of inspiration. The 
pitch is higher than that for the inspiratory sound. 
The quality is the same as that of the inspiratory 
sound, namely, tubular. 
8 



114 AUSCULTATION IN HEALTH 

Repeating the characters distinctive of the normal 
laryngeal respiration, they are as follows: The inspira- 
tory sound is of variable intensity, high in pitch, and 
tubular in qualit}^ The expiratory sound is as long 
as, or longer than, the inspiratory sound; it is higher 
in pitch, and usually more intense. Owing to the 
inspiratory sound not continuing quite to the end of 
the inspiratory act, there is a very short interval 
between the two sounds. In this latter point consists 
the only variation between the rhythm of the acts of 
breathing and that of the sounds. 

The foregoing characters should not only be verified 
by the student, but he should become so familiar 
with them by practice that it requires no effort of the 
mind to recollect them. It is especially desirable that 
he listen over the sixth and seventh cervical vertebrae 
where the sounds will be found much decreased in 
intensity, but otherwise identical with those heard 
anteriorly. For at the very outset he is too often 
merely impressed with the loudness of laryngotracheal 
breathing, instead of appreciating its more important 
qualitative characters. It will be seen hereafter that 
these characters of the normal laryngeal respiration 
are precisely those which distinguish an important 
morbid physical sign, namely, the bronchial or tubular 
respiration. 

NORMAL VESICULAR MURMUR. 

This is the name usually given to the respiratory 
sounds heard over the different regions of the chest. 



NORMAL VESICULAR MURMUR 115 

These sounds should be studied with the ear appHed 
directly to the chest (immediate auscultation), as 
well as with the stethoscope. In commencing the 
study the middle of the anterior surface of the chest 
on the right side, to avoid the sounds of the heart, or 
still better, the posterior aspect below the scapula on 
either side should be selected. The person examined 
should breathe somewhat more forcibly than in ordi- 
nary breathing, but not violently nor quickly, nor too 
slowly, the normal rhythm being unchanged. The 
mouth should be open and care taken to avoid the 
production of sounds from the nose or teeth. Chil- 
dren are better than adults for this study, owing to 
the greater intensity of the murmur in early life. 

The characters which belong to the inspiratory and 
the expiratory sound in the normal vesicular murmur 
are as follows: ''The inspiratory sound is of variable 
intensity. There is a wide variation in different 
healthy persons. In some persons it is so feeble as 
scarcely to be appreciable even with the binaural 
stethoscope. The pitch of the sounds, compared 
with the inspiratory sound in the normal laryngeal 
or tracheal respiration, is notably low. The quality 
of the sound is peculiar; no distinct idea of the quality 
can be formed by any comparison, although it roughly 
resembles the rustling of wind in the trees. The 
name used to designate the quality is vesicular, this 
name only denoting that the air vesicles are in some 
way concerned in the production of the sound {vide 
p. 32). This vesicular quality must be impressed 



116 AUSCULTATION IN HEALTH 

upon the perception and memory by direct observa- 
tion. The duration of the inspiratory sound is from 
the beginning to the end of the inspiratory act. 

"An expiratory sound is not always, although gener- 
ally, appreciable. It is much less intense than the 
sound of inspiration. It is notably lower in pitch 
than the sound of inspiration. The quality of the 
sound is neither vesicular nor tubular. It may be 
called simply a blowing sound, and may be imitated 
j by blowing with the mouth partially opened. The 

' ' duration is much shorter than that of the inspiratory 

sound, occupying only the earlier portion of the act 
of expiration." 

The characters, thus, which distinguish the normal 
vesicular murmur are, an inspiratory sound variable 
in intensity, low in pitch, and vesicular in quality; 
an expiratory sound less intense than the inspira- 
I tory, still lower in pitch, non-vesicular and non- 

tubular, or simply blowing; the inspiratory sound 
continuing from the beginning to the end of the 
respiratory act, and the expiratory sound beginning 
with the expiratory act but ending before this act is 
completed, its duration, relatively to the inspiratory 
sound, being variable, but averaging about a fifth. 
The inspiratory sound continuing to the end of inspira- 
tion, and the expiratory sound beginning with the 
act of expiration, it follows that there is no interval 
between the two sounds. It is to be remarked that 
an interval is not infrequently produced by the per- 
son examined holding the breath after inspiration is 



NORMAL VESICULAR MURMUR 117 

completed. This variation in the rhythm of the acts, 
of course, produces a corresponding variation in sounds 
of breathing. 

The characters of the normal vesicular respiration 
may be studied by inflating the lungs removed from 
the human cadaver, or from the sheep or calf, and 
applying the binaural stethoscope directly upon the 
pulmonary surface. In this experiment the vesicular 
quality is strongly marked. In the same way the 
tracheal respiration may be studied and its charac- 
ters contrasted with those of the vesicular respiration. 
This readily available method is strongly recommended 
for the study of the normal respiratory signs. 

Having become familiar with the characters of 
the normal vesicular respiration as compared with 
those of the normal laryngeal or tracheal respiration, 
the student may then proceed to study the former 
in the different regions of the chest. The murmur 
will be found to present variations in the different 
regions On the same side, and in the corresponding 
regions on the two sides of the chest. The variations, 
within the range of health, in the latter are especially 
important. The following account of the murmur 
in the different regions embodies the results of the 
analysis of a series of recorded examinations of healthy 
persons.^ 

Right and Left Infraclavicular Region. — The mur- 
mur in this region, on either side, differs more or 

1 Flint, Tr. Am. Med. Assn., 1852, vol. v. 



118 AUSCULTATION IN HEALTH 

less from the murmur as heard in the anterior regions 
below, or in the infrascapular region. The vesicular 
quality in the inspiration is less marked. The pitch 
is higher. The expiratory sound is longer, less feeble, 
and higher in pitch. The difference between the two 
sides in this region is especially important with refer- 
ence to diagnosis. The intensity of the inspiratory 
sound is almost invariably greater on the left side. 
Its vesicular quality is more marked, and the pitch 
is lower. Per contra, the inspiratory sound on the 
right side in this region, is less intense, less vesicular, 
and higher in pitch than the inspiratory sound on the 
left side. In forced breathing the intensity of the 
murmur is increased more on the left than on the right 
side. The expiratory sound is sometimes wanting 
on the left, when it is heard on the right side. On the 
right side, the expiratory sound is longer than on 
the left side. It may be prolonged on the right side 
to nearly or quite the length of the inspiratory sound. 
Sometimes on the right side the pitch of the expira- 
tory is higher than that of the inspiratory sound on the 
same side, and it may have a tubular quality. A rare 
peculiarity is a prolonged, high, tubular expiratory 
sound on both sides, analogous to the laryngeal or 
tracheal expiration. When this is the case the pitch 
of the expiratory sound is higher on the left than on 
the right side. 

The most reasonable as well as the most recent 
explanation for the differences in the respiratory 
sounds in the right and left infraclavicular regions, 



NORMAL VESICULAR MURMUR 119 

and an explanation which seems to be based on the 
best understanding of the problem, is one given by 
Fetterolf.^ He ascribes the difference in intensity and 
character of the sounds on the right side to the fact 
that the trachea is throughout practically its entire 
thoracic course in contact with the right upper lobe, 
while it is separated from the left lung by 3 cm. or 
more of large bloodvessels, and esophagus with areolar 
and lymphatic tissue. It is this intimate relation 
with the trachea which seems to account for the 
greater length of the expiratory sound on the right 
side as well as for the other characteristic differences. 

These modifications of the respirator}^ murmur in 
the infraclavicular region are marked in proportion as 
the sounds are studied near the sternum, that is, 
over the site of the primary bronchi. The respiratory 
murmur in this situation has been called the normal 
bronchial respiration, from its resemblance to the 
morbid sign so named. It may be more properly called 
a vesiculotubular, or the normal hronchovesicular 
respiration, the characters being those of the morbid 
sign to be described in the next chapter. 

In the diagnosis of diseases, especially of phthisis, 
due allowance must be made for the points of dis- 
parity which exist normally between the two sides of 
the chest in the infraclavicular region. Without a 
practical knowledge of these points of disparity, error 
in diagnosis can hardly be avoided. 

1 Arch. Int. Med., 1909, iii, No. 1. 



120 AUSCULTATION IN HEALTH 

Right and Left Scapular Region. — As compared 
with the infraclavicular region, the respiratory mur- 
mur heard over the scapula is feeble, because of the 
thickness of the tissues; and the vesicular quality is 
less marked. On the right side the inspiratory sound is 
generally weaker and the pitch higher, while the expira- 
tory sound may be prolonged and is more constantly 
heard than on the left. Compared with the left side, 
the murmur on the right thus may have vesiculotubular 
or bronchovesicular characters more or less marked. 

Right and Left Interscapular Region. — ^In the upper 
and middle portions of this region the normal char- 
acters are the same as in the sternoclavicular portion 
of the infraclavicular region. The same points of 
disparity between the two sides are more or less 
marked here as they are anteriorly over the site of 
the primary bronchi. 

Right and Left Lifrascapular Region. — The inten- 
sity of the murmur is greater than over the scapular 
region. In most persons there is no notable disparity 
between the two sides; when a disparity exists the 
intensity is greater and the pitch lower on the left 
side. A prolonged, high-pitched, bronchial expira- 
tory sound is sometimes transmitted below the scapula 
on the right side. 

Right and Left Mammary Regions. — ^The inspiratory 
sound in these regions (from the third to the sixth rib) 
is less intense than in the infraclavicular region; the 
vesicular quality is more marked, and the pitch is 
lower. An expiratory sound is often wanting. 



NORMAL VOCAL RESONANCE 121 

Right and Left Axillary and Infra-axillary Regions. — 

The inspiratory sound in these regions is as intense 
as in any portion of the chest. The intensity is less 
in the infra-axillary than in the axillary region, and 
the pitch is lower. In some persons the murmur 
on the two sides presents no disparity, but in other 
persons the vesicular quality is somewhat more 
marked and the pitch is lower on the left than on the 
right side. An expiratory sound is oftener heard than 
in the mammary regions. 

NORMAL VOCAL RESONANCE. 

Laryngeal and Tracheal Voice and Whisper. — ^Apply- 
ing the stethoscope either over the broad surface of 
the thyroid cartilage, or just above the sternal notch, 
and requesting the person examined to count with a 
moderate intensity of voice, the auscultator perceives 
a strong resonance, with a sensation of concussion or 
shock, and a sense of vibration, thrill, or fremitus. 
The voice seems to be concentrated and near the ear. 
The articulated words are transmitted so as to be 
heard more or less distinctly. The laryngeal or tracheal 
voice thus embraces different elements, namely: (1) 
The vocal resonance; (2) the concentration and near- 
ness to the ear; (3) the vibration, thrill, or fremitus; 
and (4) the transmission of the speech, the latter 
corresponding to pectoriloquy. These different ele- 
ments will be found to enter into the distinctive 
characters of morbid vocal signs. 



122 AUSCULTATION IN HEALTH 

Whispered words occasion little or no shock or thrill 
but an intense, high-pitched tubular sound, with a 
sensation as if a current of air were directed into the 
ear through the stethoscope. This sound corresponds 
to the sound of expiration in laryngeal or tracheal 
respiration; the two sounds are, in fact, identical if, 
as is the case with some exceptions, the person whisper 
with the expiratory breath. Articulated words are 
transmitted with more or less distinctness, thus cor- 
responding with the morbid sign called whispering 
pectoriloquy. 

Normal Thoracic Vocal Resonance and Fremitus. — 
The vocal resonance over the chest is to be studied 
both by means of the stethoscope and by immediate 
auscultation. In the latter the ear not applied to 
the chest should be closed in order to exclude the 
entrance of sound from the mouth of the person 
examined. When the stethoscope is employed, care 
must be taken, in making a comparison between the 
two sides of the chest, or between different regions on 
the same side, that the pectoral extremity of the 
instrument be pressed with an equal amount of force 
against the chest. The intensity with which the vocal 
resonance is transmitted is much affected by the degree 
of pressure with the stethoscope. 

The situations in which the student should com- 
mence the study of the normal vocal resonance are 
those selected for beginning the study of the normal 
vesicular murmur, namely, the middle of the anterior 
aspect of the chest on the right side, and below the 
scapula behind. 



NORMAL VOCAL RESONANCE 123 

With the stethoscope or the ear directly appHed 
in the situations just named, the person examined 
should be requested to count "One, two, three," in a 
uniform tone and with moderate force. The exami- 
ner should himself pronounce these numerals, in order 
to show the manner of counting. This is far better 
than asking a question and studying the resonance 
during the answer of the person examined. The 
objection to the latter mode is that the attention of 
the examiner is divided between the characters of 
the thoracic resonance and the idea conveyed by the 
answer. 

The characters of the vocal resonance in these situa- 
tions are as follows: The voice is heard with an inten- 
sity which varies very much in different persons; in 
some the resonance is feeble, and it may be almost 
inappreciable, while in others it is quite intense. The 
intensity depends greatly on the loudness and lowness 
in pitch of the voice of the person examined, and is 
therefore weaker in women than in men. It is rarely 
attended with a sense of concussion or shock. It is 
diffused; that is, it does not seem to be concentrated 
like the tracheal or laryngeal vocal resonance. It 
evidently comes from a certain distance; that is, the 
sound does not seem to be near the ear. Impres- 
sion of the distance of the sound is highly distinctive 
of the normal resonance as compared with a morbid 
vocal sign (bronchophony). 

The resonance is accompanied by a sense of vibra- 
tion, thrill, called vocal fremitus, the intensity of which, 



124 AUSCULTATION IN HEALTH 

like the resonance, varies much in different persons. 
This fremitus is properly not an acoustic but a tactile 
sign, due to vibrations of so low a rate as to be appreci- 
able to the sense of touch. Vocal fremitus belongs 
properly to the method of physical exploration called 
palpation. It is, however, appreciated by the ear in 
immediate auscultation, and may be studied in con- 
nection with vocal resonance. 

From the foregoing characters the normal vocal 
resonance may be defined as muffled, lacking in dis- 
tinctness of articulation, distant, variable in intensity, 
and accompanied with more or less vibration, thrill, or 
fremitus. 

Having become practically familiar with these 
characters of the normal vocal resonance in the situ- 
ations in which they are first to be studied, the next 
object of study relates to the normal variations in 
the different regions on the same side of the chest, 
and in corresponding regions on the two sides, as in 
the study of the variations of the respiratory sounds 
{vide p. 117 et seq.). 

Infraclavicular Region. — ^The vocal resonance in this 
region on either side is more intense than in the ante- 
rior regions below. Irrespective of intensity, it is less 
diffused, nearer the ear, and the pitch is somewhat 
higher. These latter variations are marked chiefly in 
the sternoclavicular extremity of the region, that is, 
over the site of the primary bronchi. In some persons 
the concentration, nearness to the ear, and elevation 
of pitch, especially on the right side, are such as to 



NORMAL VOCAL RESONANCE 125 

approximate to the morbid sign called bronchophony, 
which will be considered in the next chapter. It is 
important to know that exceptionally this may be, in 
a measure, illustrated in health in the infraclavicular 
region. The resonance may then be termed normal 
bronchophony. 

The vocal resonance on the right side is invariably 
greater. The degree of difference between the two 
sides varies in different persons. The resonance 
may be more or less marked on the right and nearly 
wanting on the left side. Allowance is to be made 
for the points of normal disparity between the two 
sides in the diagnosis of disease; hence, the student 
must become practically familiar with them.^ 

The vocal fremitus varies fully as much as the vocal 
resonance in different persons. Its intensity is not 
always proportionate to that of the resonance; that is, 
the resonance may be comparatively weak when the 
fremitus is strong, and vice versa — simply depending 
upon the proportion between the slow vibrations 
appreciable to touch and the more rapid ones appreci- 
able to the sense of hearing. The fremitus, like the 
resonance, is always greater on the right than on the 
left side, the disparity, like that of the resonance, vary- 
ing considerably in different persons. 

Scapular Region. — ^The resonance in this region is 
notably less intense than in the infraclavicular region. 
It is also more diffused and distant. The intensity 

1 For explanation, vide p. 119. (Fetterolf, Arch. Int. Med., 
1909, iii, No. 1.) 



126 



AUSCULTATION IN HEALTH 



is always greater on the right side. The same is true 
of the vocal fremitus and is simply due to the thickness 
of the intervening tissues. 

Interscapular Region. — ^The intensity of the reso- 
nance here is nearly or quite as great as in the sterno- 
clavicular extremity of the infraclavicular region. 
The resonance has in some persons in this region the 
characters of bronchophony. The intensity is always 
greater on the right side. The fremitus is more or 
less marked, and always more marked on the right 
than on the left side. 

Infrascapular Region. — As a rule the resonance in 
this region is stronger than over the scapula. It is 
always characterized by diffusion and distance. As 
in all the regions, it varies much in different persons, 
and is stronger on the right than on the left side. 
These statements are also applicable to fremitus. 

Mammary and Inframammary Regions. — ^The reso- 
nance is notably less than at the summit of the chest. 
The characters of bronchophony are never present. 
The intensity is greater on the right side. The same 
is true of fremitus. 

Axillary and Infra-axillary Regions. — ^The resonance 
in these regions, and especially in the axillary region, 
is greater than over the mammary and inframammary 
regions. It is, of course, stronger on the right side. 
The characters as contrasted with those of broncho- 
phony, namely, distance and diffusion, are marked. 
Fremitus is more or less marked, and, of course, more 
marked on the right than on the left side. 



■ NORMAL WHISPER 127 

NORMAL WHISPER. 

Prior to the publication of the author's work on the 
Physical Exploration of the Chest, in 1856, signs in 
health and disease relating to the whispered voice had 
received but little attention. It was his privilege to 
appreciate the importance of this sign, and emphasize 
its value in diagnosis. As a point of departure for 
the study of the morbid signs thus obtained, of course 
the signs in health must first be studied. 

It will facilitate the study of the normal whisper, 
as well as of the morbid signs, to consider that the 
characters of the sounds produced with the whispered 
voice are identical with those produced by the act of 
expiration, in all respects save intensity. Whispered 
words are produced, as a rule, by an act of expiration, 
the sounds being more intense generally than those 
which accompany even forced breathing. Curiously 
enough, there are exceptions to this rule. Some persons 
insist upon whispering with the act of inspiration, and 
there are some persons who have never acquired the 
ability to whisper. It will be at once evident that the 
pitch and quality of sounds, produced by whispered 
words with the act of expiration, must be the same 
as those of the sounds of expiration in breathing. 

Selecting • for the study of the normal whisper the 
same situations as in commencing the study of the 
normal respiratory murmur, and the normal vocal 
Tesonance — namely, the middle of the chest in front, 
on the right side, and the infrascapular region behind; 



128 AUSCULTATION IN HEALTH 

with the whispered voice in these situations is heard, 
in most persons, a feeble, low-pitched, blowing sound, 
these characters corresponding to those of the expira- 
tory sound in forced breathing. The normal whisper 
in these situations is not in all persons appreciable. 

In the infraclavicular region the whisper is heard, 
with variable intensity, in most persons. It is some- 
what higher in pitch than the whisper below this region. 
It is louder and higher in the sternoclavicular than in 
the acromial extremity. In the former situation it 
has not infrequently a tubular quality. It is louder 
on the right than on the left side of the chest. It is 
sometimes heard on the right when it is inappreciable 
on the left side. When heard on both sides the pitch 
of the sound is higher on the left than on the right 
side. It will be observed that these variations cor- 
respond to those of the sound with expiration in the 
infraclavicular region (vide p. 117). Occasionally whis- 
pered words are partly transmitted, constituting 
incomplete whispering pectoriloquy. 

In the scapular region the whisper is not infre- 
quently wanting. It may be present on the right and 
not on the left side, and if present on both sides it is 
always louder on the right side. 

In the interscapular region, as a rule, it is nearly 
or quite as marked as over the site of the primary 
bronchi in front. The pitch is more or less high, 
and has a tubular quality. It is louder on the right 
and higher in pitch on the left side, and in this situation 
there may be incomplete whispering pectoriloquy. 



NORMAL WHISPER 129 

In the infrascapular region it is frequently audible. 
When present it is generally feeble, the pitch being 
low and the quality non-tubular or blowing. It is 
oftener wanting on the left than on the right side, 
and, if present on both sides, it is louder on the 
right side. 

In the mammary and inframammary regions it is 
not infrequently wanting, and the statements just 
made with reference to the infrascapular region are 
alike applicable to these, as, also, to the axillary and 
infra-axillary regions. 



CHAPTER VI. 
AUSCULTATION IN DISEASE. 

The respiratory signs of Disease — Abnormal modifications 
of the normal respiratory sounds — Increased vesicular murmur 
— Diminished vesicular murmur — Suppressed respiratory sound 
— Bronchial or tubular respiration — Bronchovesicular respira- 
tion — Amphoric respiration — Cavernous respiration — Broncho- 
cavernous respiration — Vesiculocavernous respiration — Short- 
ened inspiration — Prolonged expiration — Interrupted respira- 
tion — The vocal signs of disease — Bronchophony — Whispering 
bronchophony — Egophony — Increased vocal resonance — 
Increased bronchial whisper — Cavernous whisper — Pectoriloquy 
— Amphoric voice or echo — Diminished and suppresiSed vocal 
resonance — Diminished and suppressed vocal fremitus — Metallic 
tinkling — Signs obtained by acts of coughing, or tussive sounds 
— Adventitious respiratory sounds, or rales — Laryngeal and 
tracheal rales — Moist bronchial rales : coarse, fine, and subcrepi- 
tant — Dry bronchial rales — Vesicular or crepitant rale — Cavern- 
ous or gurgling rale — Pleural friction rales, metallic tinkling and 
splashing — Indeterminate rales. 

The auscultatory signs of disease, which are to be 
considered in this chapter, should not be studied until 
the student has made himself complete master of all 
the characters belonging to the normal signs obtained 
by auscultation. For our criterion for the detection 
of disease by auscultation consists merely in the 
recognition of sounds modified beyond the limits of 
normal variations. 



THE NORMAL RESPIRATORY SOUNDS 131 

Auscultation in disease embraces the signs produced 
by respiration, voice, whisper, and by acts of coughing. 
The respiratory signs will be first considered. 

THE RESPIRATORY SIGNS OF DISEASE. 

The morbid signs produced by respiration may be 
classified as follows: (1) Those which are abnormal 
modifications of the normal respiratory sounds; (2) 
those which have no analogues in health, being 
entirely new or adventitious sounds. The latter are 
usually embraced under the name rales. 

ABNORMAL MODIFICATIONS OF THE NORMAL 
RESPIRATORY SOUNDS. 

In order to appreciate the distinctive characters 
of the abnormal breath sounds, the characters which 
distinguish the normal vesicular murmur must be 
kept in mind. The modifications which characterize 
these morbid signs relate to intensity, pitch, and 
quality of sound, together with certain alterations in 
rhythm. Twelve signs are included under this heading, 
namely: (1) Increased vesicular murmur; (2) dimin- 
ished vesicular murmur; (3) suppression of respiratory 
sound; (4) bronchial or tubular respiration ; (5) broncho- 
vesicular respiration; (6) cavernous respiration; (7) 
bronchocavernous respiration; (8) vesiculocavernous 
respiration; (9) amphoric respiration; (10) shortened 
inspiration; (11) prolonged expiration; (12) interrupted 
respiration. 



132 AUSCULTATION IN DISEASE 

These signs are to be studied (1) with reference to 
their distinctive characters contrasted with the other 
morbid respiratory signs as well as with the normal 
vesicular murmur; and (2) with reference to the morbid 
physical conditions which they severally represent, 
that is, their diagnostic significance. 

Increased Vesicular Murmur. — This sign has but a 
single distinctive character, namely, increase of inten- 
sity. The murmur is abnormally loud, the characters 
of the normal vesicular murmur being in other respects 
not materially changed, that is, the pitch is low and 
the quality vesicular as in health. Now, it has been 
seen {vide p. 115) that the intensity of the healthy 
murmur varies much in different persons. There is no 
ideal standard of normal intensity by reference to 
which an abnormal increase is to be determined. Yet 
the increase under certain conditions of disease is such 
that the fact is sufficiently evident. 

It occurs on the healthy side of the chest when the 
respiratory function on the other side is annulled or 
much compromised by disease. This takes place in 
cases of pleurisy with large effusion, pneumonia, 
especially if more than one lobe be affected, obstruction 
of one of the primary bronchi, and in pneumothorax. 
The sign does not possess greater diagnostic importance 
inasmuch as the nature and extent of the disease are 
ascertained by the signs obtained on the affected side. 

The sign has been called compensatory and puerile 
respiration. 

If the murmur be much intensified, it may possibly 



THE NORMAL RESPIRATORY SOUNDS 133 

be mistaken for other morbid signs, namely, bron- 
chial or bronchovesicular respiration. This error, how- 
ever, can never be made if the distinctive characters 
of these signs relating to pitch and quality have been 
correctly studied. 

Diminished Vesicular Murmur. — The intensity of the 
vesicular murmur may be, on the one hand, diminished, 
although unaltered in other respects; and the murmur, 
on the other hand, may become so feeble that char- 
acters aside from the intensity are not determinable. 

The murmur is more or less weakened in cases of 
dilatation of the air cells, or vesicular emphysema, in 
which the quantity of the tidal air is decreased in 
proportion to the volume of the lungs; while gradual 
giving way of the lung elastic tissues has resulted in 
the fibers being put under less than normal tension 
by the act of inspiration. The sign in these cases is 
often accompanied by changes in rhythm, namely, a 
shortened inspiration and a prolonged expiration. 

Simple weakness of the murmur may also be incident 
to partial blocking of the air vesicles and bronchioles 
with blood or serum in cases of pulmonary extravasation 
and edema. 

A deficient expansion of the chest, either on one 
side or on both sides, occasions weakness of the 
respiratory murmur. Deficient expansion of one side, 
or of both sides, may be caused by paralysis, bilateral 
or unilateral, of the costal muscles. A similar effect 
is caused by paralysis of the diaphragm. The incom- 
plete descent of the diaphragm from pain, as in peri- 



134 AUSCULTATION IN DISEASE 

tonitis, or from mechanical obstacles, as in peritoneal 
dropsy, pregnancy, and abdominal tumors, weakens the 
respiratory murmur, the increased action of the costal 
muscles not being fully compensatory. Unilateral defi- 
ciency of expansion of the chest is caused by pain in 
intercostal neuralgia, pleurodynia, acute pleurisy, and 
pneumonia; it is also caused by the presence of a stra- 
tum of liquid, air, or a thick layer of lymph, between 
the lung and the chest wall in pleurisy, hydrothorax, 
and pneumothorax. Swelling of the bronchial mucous 
membrane in bronchitis affecting the larger tubes, 
must diminish somewhat the intensity of the murmur. 
In primary bronchitis the murmur is diminished on 
both sides. In bronchitis affecting the smaller tubes 
the murmur is greatly diminished, if not suppressed, 
on both sides. Incomplete obstruction of bronchial 
tubes from the presence of mucus, serum, blood, or 
pus, has this effect over an area corresponding to the 
size of the tubes obstructed. Spasm of the bronchial 
muscular fibers in paroxysms of asthma, diminishes, if 
it does not suppress, murmur on both sides. Another 
cause of diminution, unilateral or within a limited 
space on one side, is the presence of a tumor pressing 
on bronchial tubes, as in cases of aneuryim. A 
permanent contraction or stricture of bronchial tubes 
is another cause. Not infrequently the pressure of 
an aneurismal tumor or an enlarged bronchial gland 
on a primary bronchus occasions notable weakness 
of the murmur over the whole of one side; and the 
pressure of a tumor on the trachea weakens the mur- 



THE NORMAL RESPIRATORY SOUNDS 135 

mur, more or less, on both sides. A foreign body in 
one of the primary bronchi weakens it on one side. 
Diminution of the cahbre of the trachea or larynx 
from morbid growths, the presence of foreign bodies, 
fibrinous exudations, accumulations of mucus, sub- 
mucous infiltration, spasms of the laryngeal muscles, 
and swelling of the mucous membrane, weakens, in 
proportion to the amount of obstruction, the murmur 
on both sides without any material change in its 
quality and pitch. 

Weakened murmur at the summit of the chest, 
without other appreciable abnormal characters, occurs 
in some cases of phthisis, due to obstructed bronchial 
tubes from coexisting circumscribed bronchitis, or to 
deficient superior costal movements of the chest, as well 
as to the presence of exudation in the air vesicles. 

Diminished intensity of the vesicular murmur is 
thus seen to be a respiratory sign entering into the 
diagnosis of a considerable number of diseases, namely, 
emphysema, paralysis affecting the respiratory muscles, 
asthma, abdominal affections interfering with the 
diaphragmatic movements, intercostal neuralgia, pneu- 
monia, fibrinous pleurisy, hydrothorax, bronchitis, 
aneurismal and other tumors, permanent constriction 
or stricture of bronchial tubes, laryngitis, edema of 
the glottis, spasm of the glottis, the various lesions 
which occasion obstruction of the larynx or trachea, 
and phthisis. 

In determining a slight abnormal weakness of the 
respiratory murmur at the summit of the chest on 



136 AUSCULTATION IN DISEASE 

the right side, the normal disparity between the two 
sides in this situation is to be borne in mind. The 
vesicular murmur is normally less intense on the right 
than on the left side. 

This sign occurring in so many diseases, it is obvious 
that, taken alone, that is, independent of other signs, 
it has no special diagnostic significance. It is, how- 
ever, often of value in diagnosis, when taken in con- 
nection with other signs. It is chiefly useful when it 
exists either over the whole or in a part of the chest 
on one side. 

Suppressed Respiratory Sound. — Absence of all respira- 
tory sound, as the name signifies, cannot, of course, 
have any characters relating to intensity, pitch, and 
quality. 

Suppression of respiratory sound represents the 
same physical conditions as diminished vesicular mur- 
mur; the physical conditions represented by the latter 
sign, existing in a greater degree, occasion absence of 
all sound. It suffices, therefore, to recapitulate the 
various conditions and diseases in connection with 
which the murmur may either be diminished or sup- 
pressed. Suppression over portions of the chest may 
be due to dilatation of the air cells in cases of emphy- 
sema. It occurs from the exclusion of air from the 
vesicles by the presence of blood and serum in cases 
of pulmonary extravasation and edema. Respiratory 
sound is sometimes wanting over lung solidified in 
cases of pneumonia and phthisis when the exudate has 
occluded the bronchial tubes (massive consolidation). 



THE NORMAL RESPIRATORY SOUNDS 137 

Paralysis of the muscles concerned in respiration 
may possibly involve feebleness of the respiratory acts 
sufficiently to render the murmur inappreciable. In 
intercostal neuralgia, pleurodynia, acute pleurisy, 
and pneumonia, the movements of the affected side 
may be so much restricted as to abolish the murmur. 
In pleurisy with much effusion, empyema, hydro- 
thorax, and pneumothorax, the murmur is suppressed 
over either a part or the whole of the affected side, 
the extent of the suppression corresponding to the 
quantity of serum, pus, or air within the pleural 
cavity. 

Swelling of the mucous membrane in cases of 
bronchitis affecting the larger bronchial tubes is never 
sufficient to suppress the murmur, but plugging of 
more or less of the tubes with mucus or other morbid 
products may have this effect. In cases of bronchitis, 
the murmur is sometimes found to have disappeared 
over a certain area, and to return after an act of 
expectoration. In bronchitis affecting the smaller 
tubes, suppression of the murmur is not infrequent. 
It occurs from spasm of the bronchial muscular fibers 
in cases of asthma. The pressure of a tumor, morbid 
growths, or deposits from bronchi, within the lungs, 
may abolish respiratory sound over a portion of the 
chest, and permanent stricture or obliteration of 
bronchial tubes must have this effect. Respiratory 
sound may be suppressed over the whole of one side 
from the pressure of an aneurismal or some other 
tumor upon one of the primary bronchi. If the tumor 



138 AUSCULTATION IN DISEASE 

press upon the trachea, the obstruction may be suffi- 
cient to suppress the murmur on both sides. A 
foreign body lodged in a primary bronchus may sup- 
press the murmur on one side, and, lodged in the 
larynx or trachea, the murmur may be suppressed on 
both sides. The different affections of the larynx and 
trachea which, in proportion to the amount of obstruc- 
tion, weaken the murmur, may render it inappreciable. 
Bronchial or Tubular Respiration. — The analogue of 
this sign is the normal laryngeal or tracheal respi- 
ration (vide p. 112). The characters which distinguish 
the latter normal sign from the normal vesicular 
murmur, are' those which are distinctive of the bron- 
chial or tubular respiration. These characters, relat- 
ing to the inspiratory and expiratory sounds, are as 
follows: The inspiratory sound is of variable intensity. 
Intensity does not enter into the distinctive characters 
of this sign; the sound may be either louder or weaker 
than the inspiratory sound in health. The pitch of 
the inspiratory sound is high. The quality is expressed 
by the term tubular; it is like the sound produced 
by blowing through a tube, this quality taking the 
place of that expressed by the term vesicular in the 
normal respiration. The expiratory sound is pro- 
longed; it is as long as, or longer than, the sound of 
inspiration, and is usually louder. The pitch is still 
higher than that of the inspiratory sound. The 
quality, like that of the inspiratory sound, is tubular, 
this quality taking the place of the simple blowing 
quality of the expiratory sound in the normal vesicular 



THE NORMAL RESPIRATORY SOUNDS 139 

murmur. With the normal rhythm of the respiratory 
acts there is a very brief interval between the sounds 
of inspiration and expiration, due to the fact that the 
inspiratory sound ends a little before the end of the 
inspiratory act. 

The morbid physical condition represented by bron- 
chial breathing is either complete or considerable solidi- 
fication of lung with the larger bronchi is still patent 
(vide p. 30). Whenever the chest is auscultated over 
lung solidified, if there be not absence of respiratory 
sound, the sound is tubular. This significance renders 
the sign of diagnostic value in the diseases which 
involve solidification. The sign per se, denotes simply 
this morbid physical condition; the particular disease 
which exists is ascertained by means of the associated 
signs and the symptoms. 

Solidification of lung is incident to several different 
diseases. In lobar pneumonia it is due to a fibrinous 
exudation within the air vesicles. In phthisis it is 
caused by an exudation in the same situation. In 
chronic or fibroid pneumonia the lung is solidified by 
an interstitial growth. The compression of lung from 
either pleuritic effusion, an accumulation of air in the 
pleural cavity, or the pressure of a tumor, causes 
solidification by condensation. Collapse of pulmonary 
lobules also solidifies by condensation. Coagulation of 
blood within the air vesicles (hemorrhagic infarctus) 
and neoplastic infiltration or growth are other causes 
of solidification. In these different affections, if the 
solidification be complete or considerable, this sign is 



140 AUSCULTATION IN DISEASE 

usually present; it is always present if there be not 
suppression of respiratory sound. 

It is sometimes the ease that either the inspiratory 
or the expiratory sound is wanting. The characters 
of the sign suffice for its recognition if either the inspi- 
ratory or the expiratory sound be alone present; the 
pitch and the quality are distinctive. Both sounds 
are often so intense that they are diffused more or 
less beyond the limits of the solidified portion of 
lung. The expiratory sound, being more intense than 
the inspiratory, is transmitted farther than the latter. 
This explains the conjunction sometimes of a vesicular 
inspiration with a tubular expiration; and a cavernous 
inspiration may be conjoined with a tubular expira- 
tion, showing the proximity of solidified lung in the 
former case to healthy lung, and in the latter case to a 
pulmonary cavity. 

The sound may seem near the ear, or to come from 
a certain distance. The latter is appreciable in some 
cases of large pleuritic effusion; the tubular respira- 
tion is more or less distant, and it is sometimes 
diffused over the whole of the side which is filled with 
liquid. 

Bronchovesicular Respiration. — This name was intro- 
duced by me, in 1856, to denote the combination, 
in varying proportions, of the characters of the bron- 
chial or tubular, and of the normal vesicular respira- 
tion. The name expresses such a combination. It 
embraces modifications to which have been applied 
the terms, rude, rough, and harsh respiration, and 



THE NORMAL RESPIRATORY SOUNDS 141 

those included by German authors under the name 
indeterminate respiratory sounds. 

The sign represents the different degrees of soHdi- 
fication of lung, between an amount so slight as to 
occasion only the smallest appreciable modification 
of the respiratory sound, and an amount so great as 
to approximate closely to the degree giving rise to 
bronchial or tubular respiration. In other words, 
all the gradations of respiratory modifications, caused 
hy incomplete or an inconsiderable solidification, which 
fall short of bronchial or tubular respiration, are 
embraced under the name bronchovesicular. The 
gradations correspond to the amount of solidification, 
that is, they show the solidification to be either 
very slight, slight, moderate, or nearly sufficient to 
be considered as considerable or complete. The sign 
is therefore important as evidence (1) of the existence 
of solidification; and (2) of the degree of solidification. 

Analyzing this sign, the most distinctive feature is 
the combination of the vesicular and the tubular quality 
in the respiratory sound. These two qualities may 
be combined in variable proportions. The pitch of 
the sound is raised in proportion as the tubular pre- 
dominates over the vesicular quality. The expiratory 
sound is more or less prolonged, tubular in quality, 
and the pitch is raised. The prolongation of this 
sound, its tubular quality, and the highness of pitch, 
are proportionate to the predominance of the tubular 
over the vesicular quality in the inspiratory sound. 

If the solidification of lung be slight, the characters 



142 AUSCULTATION IN DISEASE 

of the normal vesicular respiration predominate; that 
is, the inspiratory sound has but a small proportion 
of the tubular quality, and is but little raised in pitch, 
the expiratory sound being not much prolonged, its 
tubularity not marked, the pitch not high. If, on the 
other hand, the solidification of lung be almost enough 
to give a bronchial respiration, the inspiratory sound 
has only a little vesicular quality, the tubular quality 
predominating, the pitch proportionately raised; and 
the expiratory sound is prolonged, tubular, and high, 
nearly to the same extent as in the bronchial respiration. 
The less the solidification, the more the characters of 
the normal vesicular predominate over those of the 
bronchial respiration, and, per contra, the greater the 
solidification, the more the characters of the bronchial 
predominate over those of the normal vesicular 
respiration. Daily auscultation in a case of lobar 
pneumonia during the stage of resolution affords an 
opportunity to study all the gradations of this sign. 
After resolution has made some progress the inspiratory 
sound is no longer purely tubular, but the ear appre- 
ciates a little admixture of the vesicular quality and 
the pitch is slightly lowered. As resolution goes on 
the vesicular quality increases, the pitch is correspond- 
ingly lowered, until, at length, no tubularity remains, 
and the pitch becomes normal. Meanwhile, as the 
vesicular quality increases in the inspiratory sound, 
the expiratory sound is less and less prolonged, high 
and tubular; until it becomes, as in health, short, low, 
and blowing. 



THE NORMAL RESPIRATORY SOUNDS' 143 

The bronchovesicular respiration is an important 
diagnostic sign in all the affections which involve 
partial solidification of lung. In lobar pneumonia, 
as just stated, it denotes the progress made from day 
to day in resolution. It is found also in an earlier 
stage, before the solidification is sufficient to give 
rise to a purely bronchial respiration. It is a valu- 
able sign in phthisis, affording evidence, not only of 
the fact of solidification, but of its degree and extent. 
The sign enters into the diagnosis of interstitial pneu- 
monia, hemorrhagic infarctus, condensation of lung 
from the pressure of either liquid, air, or a tumor, 
and from collapse of pulmonary lobules. It may be 
stated with respect to this sign, that it is always 
present if the lung be partially . solidified, provided 
there be not either suppression of respiratory sound, 
or such a degree of feebleness that the distinctive 
characters are undeterminable. As with the bron- 
chial respiration, so wdth the bronchovesicular, either 
the inspiratory or the expiratory sound may be want- 
ing. The characters of the sign are then to be deter- 
mined as they are manifested in the sound which is 
present, namely, the combination of the vesicular 
and the tubular quality, with more or less elevation 
of pitch, if only an inspiratory sound may be heard; 
and the amount of prolongation, tubularity, and 
elevation of pitch, if there be only an expiratory sound. 

In determining the presence of this morbid sign 
at the summit of the chest on the right side, it is to 
be borne in mind that the respiratory murmur on 



144 AUSCULTATION IN DISEASE 

this side has, in health, as compared with the respi- 
ratory murmur at the summit on the left side, more 
or less of the characters of the bronchovesicular respi- 
ration (vide Normal Bronchovesicular Respiration, p. 
119). 

Amphoric Respiration. — This sign grades impercep- 
tibly into cavernous respiration (vide p. 34), from 
which many authors do not distinguish it. The term 
amphoric denotes a musical intonation which may be 
compared to the sound produced by blowing upon the 
open mouth of a decanter or phial. Whenever the 
respiratory sound has this intonation it denotes a 
large space containing air. Air in the pleural cavity, 
with perforation of lung, is the physical condition 
most frequently represented by this sign. It is a 
valuable diagnostic sign in cases of pneumothorax; 
but it is not always present in that affection, certain 
accessory conditions being requisite — namely, per- 
foration above the level of liquid, and an unobstructed 
communication of the bronchial tubes, through the 
opening, with the pleural space containing air. While, 
therefore, its presence is significant of pneumothorax, 
its absence is by no means sufficient to exclude this 
affection. Not infrequently it is a sign of a phthisical 
cavity with walls which do not collapse with the act 
of respiration. The same contingencies affect its 
production here as in cases of pneumothorax. When- 
ever amphoric respiration is present, if pneumothorax 
be excluded by the absence of the other signs which are 
diagnostic of this affection, the sign is proof of the 



THE NORMAL RESPIRATORY SOUNDS 145 

existence of a pulmonary cavity, the walls of which 
are not flaccid. The sign then takes the place of the 
ordinary cavernous respiration which is to be described 
below. 

The amphoric sound may accompany either inspi- 
ration or expiration, or both. Amphoric respiration 
may be artificially illustrated by connecting an India- 
rubber bag of considerable size (such as is contained 
within a football) with a flexible tube, and after dilat- 
ing it with air, inflating it forcibly either by a pair of 
bellows or by the mouth, holding the bag close to the 
ear. The amphoric sound thus produced represents 
the amphoric respiration as a sign in pneumothorax. 
As the sign of a tuberculous cavity it may be illus- 
trated by a similar experiment, using an India-rubber 
bag of the size of an egg or orange. I have localized a 
tuberculous cavity with rigid walls in the centre of a 
lobe by artificially inflating phthisical lungs after their 
removal from the body. / 

Cavernous Respiration. — The modifications which 
constitute the distinctive characters of this sign are 
produced by the entrance of air into a cavity with 
the act of inspiration, and its exit from the cavity 
with the act of expiration. This passage of air into 
and from a cavity can only take place where the 
walls of the cavity collapse more or less in expira- 
tion and expand in inspiration. Pulmonary cavities 
occur chiefly in cases of phthisis. They occur, but 
with comparative infrequency, as a result of circum- 
scribed abscess and gangrene of lung. 
10 



146 AUSCULTATION IN DISEASE 

A well-marked cavernous respiration has char- 
acters which are highly distinctive when this sign is 
contrasted, on the one hand, with either the bron- 
chial or bronchovesicular respiration, and, on the 
other hand, with the normal vesicular murmur. These 
distinctive characters relate both to the inspiratory 
and expiratory sound. The inspiratory sound is 
neither vesicular nor tubular in quality, and the 
pitch is low as compared with the bronchial respira- 
tion. As regards quality, we may say of it, as of 
the expiratory sound in the normal vesicular respira- 
tion, it is simply a blowing sound. The expiratory 
sound has the same quality as the inspiratory, and 
it is lower in pitch. Its duration is variable. The 
intensity of both the inspiratory and the expiratory 
sound varies; intensity does not enter into the dis- 
tinctive characters of this sign more than into those 
of the bronchial and the bronchovesicular respiration. 
With a practical knowledge of the foregoing characters 
distinctive of the cavernous respiration, there is no 
difficulty in discriminating this sign from the bronchial 
respiration. The sign is more likely to be confounded 
with the normal vesicular murmur, inasmuch as it 
differs from the latter only in the absence in the inspi- 
ratory sound of the vesicular quality. Against this 
error the student is to be cautioned. It is most likely 
to be made when the inspiratory sound is much weak- 
ened, and, consequently, the vesicular quality less 
distinctly appreciable. 

A cavernous respiration is limited to a space more 



THE NORMAL RESPIRATORY SOUNDS 147 

or less circumscribed, the area corresponding to the 
site and the size of the cavity. Occurring, for the 
most part, in cases of phthisis, it is much oftener 
found at the summit than elsewhere over the 
chest. It is not constantly found where there is a 
cavity with flaccid walls. It may be temporarily 
suppressed by the presence of liquid within the cavity, 
and by obstruction of the orifices communicating 
with bronchial tubes. It may be wanting at one 
moment, and an act of expectoration may cause 
it to reappear. Hence absence of cavity cannot be 
predicated on the absence of the sign at a single 
examination. Moreover, if a cavity be not situated 
near the pulmonary superficies, and solidified lung 
intervene between it and the walls of the chest, the 
cavernous sign may be drowned in a loud bronchial 
respiration. For this reason, while the cavernous 
sign is positive evidence of a cavity, the absence of 
the sign is not proof that a cavity does not exist. 

In some cases of perforation of lung with pneumo- 
thorax, the passage of air to and fro through the per- 
foration may give rise to the cavernous respiration. 
But, as a rule, the resonating properties of such large 
air chambers are so productive of overtones that the 
more musical sounds called amphoric respiration are 
found. 

The cavernous respiration may be reproduced by 
the inflation of lungs after their removal from the 
body, the binaural stethoscope being placed over a 
cavity. This is true, also, of the bronchial and the 



148 AUSCULTATION IN DISEASE 

bronchovesicular respiration. These signs may be 
thus ilkistrated not infrequently after death from 
phthisis in huigs in which are cavities together with 
portions completely or moderately solidified. 

The distinctive characters of the cavernous respi- 
ration may also be illustrated by means of a small 
India-rubber balloon with openings at opposite ends. 
Inflating the balloon through a tube introduced into 
one opening produces a sound analogous to the caver- 
nous inspiration, and the expulsion of the air by the 
elasticity of the balloon produces a sound analogous to 
the cavernous expiration. A Davidson syringe may 
be used to inflate the balloon. The sounds are heard 
by applying lightly to the balloon the binaural stetho- 
scope. This illustration demonstrates the mechanism 
of the cavernous respiration. 

Bronchocavernous Respiration. — In this sign, as the 
name denotes, the characters of the bronchial and 
the cavernous respiration are combined. These char- 
acters may be combined in different ways, as well 
as in variable proportions. If a cavity be situated 
in proximity to solidified lung, the quality and pitch 
of the inspiratory and the expiratory sound may 
show an admixture of the characters of the two signs, 
and to a practised ear the combination is distinctly 
recognizable. This is one of the forms of broncho- 
cavernous respiration; the sounds are not sufficiently 
high and tubular for bronchial, nor sufficiently low 
and blowing for cavernous respiration. Another form 
consists of an inspiratory sound, the first part of 



THE NORMAL RESPIRATORY SOUNDS 149 

which is tubular, and the latter part cavernous. 
Examples of this form are not extremely infrequent 
(metamorphosing respiration). Still another form is 
a cavernous inspiratory, with a bronchial or tubular 
expiratory sound. » In the latter form the bronchial 
expiration proceeds from solidified lung situated near 
the cavity, the intensity of the sound being sufficient 
to drown the cavernous expiration. 

When, as often happens, a cavity is situated in 
close proximity to, or, it may be, surrounded by 
solidified lung, the cavernous and the bronchial 
respiration are, as it were, in juxtaposition, and such 
instances offer an excellent opportunity to study the 
points distinguishing these signs from each other; 
and, generally, at a short distance the normal vesicular 
murmur may be found, so that both morbid signs 
may be compared with the latter. Within a circum- 
scribed area sometimes are exemplified the characters 
of the normal murmur, and of the two morbid signs 
just mentioned, together with those of the broncho- 
vesicular respiration. 

Vesiculocavernous Respiration. — It is sometimes evi- 
dent that the vesicular and the cavernous quality are 
combined in the inspiratory sound. This occurs 
when a cavity is surrounded, not by solidified, but 
by healthy lung. Under these circumstances, over 
the site of the cavity the inspiratory sound may be 
as loud as, or louder than, that around the cavity, 
but the quality is not purely cavernous; some vesicular 
quality is appreciable. A vesiculocavernous respira- 



150 AUSCULTATION IN DISEASE 

tion, then, is a cavernous respiration plus some vesicu- 
lar quality derived from the air vesicles which are 
proximate to the cavity. 

Shortened Inspiration. — The inspiratory sound is 
somewhat shortened in bronchial respiration. This 
modification enters into the characters of that sign, 
the quality of the sound being tubular, and the pitch 
high. The shortening is due to the sound ending 
before the inspiratory act ends; the sound is said to 
be unfinished. 

Shortening of the sound occurs, however, when it 
is not an element in the bronchial respiration. The 
shortening is then due to the sound not beginning 
with the inspiratory act; this is distinguished as 
deferred inspiratory sound. A deferred inspiratory 
sound not tubular in quality, but more or less vesicu- 
lar, and not notably raised in pitch, is a sign of pul- 
monary or vesicular emphysema. It is a sign of value 
in connection with the diagnosis of that disease. 

The student should note the distinctions just stated, 
which relate to pitch and quality. Suppose an inspi- 
ratory sound to be present without an expiratory 
sound; if the sound be shortened at the end of the 
inspiration, the pitch high, and the quality tubular, 
it is bronchial respiration, denoting complete or 
considerable solidification of lung; but if the short- 
ening be at the beginning of inspiration, the pitch 
comparatively low, and vesicular quality be appre- 
ciable, the sign denotes emphysema. The differential 
points thus are the inspiratory sound either unfinished 



THE NORMAL RESPIRATORY SOUNDS 151 

or deferred, the pitch either high or low, and the 
quaUty either tubular or vesicular. Attention to 
these points is essential in order to avoid error in the 
interpretation of the sign. 

Prolonged Expiration. — The length of the expira- 
tory sound in health varies in different persons. The 
sound is sometimes considerably prolonged; it may 
be nearly as long as the sound of inspiration. There 
is no difficulty in recognizing this as a normal pecu- 
liarity, from the fact that the murmur has the pitch 
and quality of health. 

An unusual length of the expiratory sound, within 
the range of health, is usually observed at the summit 
of the chest, and especially on the right side. It 
is important to bear in mind that at the summit of 
the chest on the right side, and sometimes also on the 
left side, a prolonged expiratory sound, more or 
less raised in pitch, and tubular in quality, may be a 
normal peculiarity. It follows that a prolonged and 
even a high and tubular expiration at the summit 
of the chest must not be reckoned as a morbid sign 
unless it be associated with other signs denoting disease. 
The laws of the disparity between the two sides of the 
chest at the summit are to be taken into account 
(vide p. 117). If the expiration be longer on the left 
than on the right side, it is abnormal; so, also, is a 
high-pitched tubular expiration heard on the left and 
not on the right side. 

The significance of an abnormally prolonged expira- 
tion depends on its pitch and quality. If it be high 



152 AUSCULTATION IN DISEASE 

and tubular, it denotes solidification of lung. It is, 
in fact, bronchial respiration. As already stated, in 
bronchial or tubular respiration the inspiratory sound 
is sometimes wanting, and the presence of the sign 
is then to be determined by the characters, relating 
to pitch and quality, of the expiratory sound. The 
same statement holds true with respect to broncho- 
vesicular respiration, when this approximates to the 
bronchial. At the summit of the chest, the characters 
of the inspiratory sound, and associated morbid signs, 
always enable the auscultator to determine whether 
a prolonged high and tubular expiration be, or be not, 
abnormal. A prolonged expiration, which is low in 
pitch and blowing in quality, that is, with the char- 
acters of health, aside from length, may belong to a 
cavernous expiration. This is to be determined by 
the characters of the inspiration and by other asso- 
ciated signs. Exclusive of cavernous respiration, an 
abnormally prolonged expiratory sound of low pitch 
and non-tubular denotes vesicular emphysema. It 
is associated then with a weakened and deferred 
inspiratory sound. A prolonged expiratory sound, in 
cases of emphysema, is invariably low and non- 
tubular. If it have not these characters, it is not 
a sign of emphysema, but belongs to bronchial or 
bronchovesicular respiration. 

A prolonged expiration at the summit of the chest 
on the right side is sometimes incorrectly considered 
to be evidence of phthisis. It is to be recollected, 
in the first place, that prolongation of this sound 



THE NORMAL RESPIRATORY SOUNDS 153 

with a normal pitch and quaHty, is never evidence 
of sohdification of lung either from phthisis or any- 
other disease; and in the second place, even if the 
pitch be high, and the quality tubular, that it is not 
to be regarded as abnormal provided the inspiratory 
sound is unchanged, and other signs of disease are 
not present. At times in bronchitis, there is a pro- 
longed expiratory sound which may be distinguished 
as a sonorous expiration, not amounting to a rale. 
This is likely to be mistaken for bronchovesicular 
breathing. 

Interrupted Respiration. — To this sign have been 
applied other names, such as jerking, wavy, or cog- 
wheel breathing. The modification is either of the 
inspiration or of the expiration, or of both. The 
inspiratory, however, much more frequently than 
the expiratory sound is interrupted. The sound 
instead of being continuous, is broken into one, two, 
or more parts. If at the same time there be altera- 
tions in pitch and quality, the interruption is merely 
incidental to other signs — namely, the bronchial, 
bronchovesicular, or cavernous respiration. As a 
distinct sign it has but little diagnostic value. 

Interrupted respiration is sometimes found in 
healthy persons. It is confined to the summit of the 
chest, and oftener on the left than the right side. 
Existing without any other signs, therefore, it is 
not evidence of disease. It is of value only in the 
diagnosis of phthisis. Associated with other signs, 



154 AUSCULTATION IN DISEASE 

when the latter are not marked, it is entitled to a 
certain amount of weight in the diagnosis. 

Interrupted respiratory sounds, of course, occur 
when there is interruption in the respiratory move- 
ments. This happens in cases of pleurisy, pleuro- 
dynia, or intercostal neuralgia. Owing to the pain 
caused by the movements in respiration, the patient 
may breathe, not continuously, but with a series of 
jerking movements. Sometimes interrupted breathing 
is observed in persons who are excited or agitated 
when auscultation is practised. In all these instances 
interruption in the respiratory sounds is found over the 
whole chest, whereas, when it is an abnormal sign in 
cases of phthisis, it is limited to a localized area. 

. Summary. — Reviewing the foregoing signs, they 
may be distributed into three classes, as follows: (1) 
Signs, the distinctive characters of which relate either 
to the absence or to the intensity of sound. This 
class embraces (a) increased intensity of the vesicular 
murmur; (b) diminished intensity of the vesicular 
murmur; and (c) suppression of respiratory sound. 
(2) Signs, the distinctive characters of which relate 
especially to pitch and quality. In this class belong 
(a) bronchial or tubular respiration; (b) broncho- 
vesicular respiration; (c) amphoric and cavernous 
respiration; (d) bronchocavernous respiration; and 
(e) vesiculocavernous respiration. (3) Signs, the 
distinctive characters of which relate especially to 
rhythm — namely, (a) shortened inspiration; (b) pro- 
longed expiration; and (c) interrupted respiration. 



li 



BRONCHOPHONY 155 

THE VOCAL SIGNS OF DISEASE. 

TJie vocal signs of disease, with the exception of 
metallic tinkling, which is a vocal as well as respi- 
ratory sign, may all be considered as abnormal modi- 
fications of the normal vocal resonance and of the normal 
whisper. The student must therefore be familiar 
with the distinctive characters of these two normal 
signs before entering upon the study of the abnormal 
modifications {vide pp. 121 and 127). We must bear 
in mind the facts which have been presented in rela- 
tion to the normal vocal fremitus {vide p. 123). The 
rules given for auscultation of the voice are also to be 
observed {vide p. 110). Embracing the abnormal 
modifications of the voice, the whisper and fremitus, 
the following are the signs to be considered: Bron- 
chophony; whispering bronchophony; egophony; in- 
creased vocal resonance; increased bronchial whisper; 
cavernous whisper; pectoriloquy; amphoric voice or 
echo; diminished and suppressed vocal resonance; 
diminished and suppressed vocal fremitus, and metallic 
tinkling. 

BRONCHOPHONY. 

Bronchophony has the same import as bronchial or 
tubular respiration. It occurs when the muffling 
action of normal alveoli {vide p. 30 ff.) is abolished. 
Therefore its presence indicates, like bronchial breathing, 
that the lung is completely or largely consolidated. Gen- 



156 AUSCULTATION IN DISEASE 

erally the two signs are associated, but either may be 
present without the other. 

The characters which are distinctive of broncho- 
phony, as compared with normal vocal resonance, are 
these : The vocah sound seems concentrated, in most 
cases nearf. the ear, the articulation clear-cut, and 
the pitch is more or less raised. These characters are 
in contrast with the diffusion, distance, and lowness 
of pitch of the normal vocal resonance. The inten- 
sity of the sound is variable; it may be greater or 
less than the intensity of the normal resonance. A 
concentrated, high-pitched sound, however feeble, is 
not less a sign of complete or considerable solidification 
of lung. In other words, intensity is not essential. 

Vocal fremitus is always to be discriminated from 
vocal resonance. The. fremitus associated with bron- 
chophony may, or may not, be greater than the 
fremitus of health. Vocal fremitus while usually 
increased, is not infrequently less than in health. 

It is to be borne in mind that in some healthy per- 
sons bronchophony exists at the summit of the chest, 
especially on the right side, over the primary bronchus, 
and also because of the close proximity of the trachea 
(vide p. 119). Existing in this situation it may not 
be abnormal. 

Representing complete or considerable solidifica- 
tion of lung, this sign occurs in the different affections 
in which bronchial or tuhidar respiration has been 
seen to occur {vide p. 139), namely, lobar pneumonia, 
phthisis, chronic or fibroid pneumonia, condensation 



WHISPERING BRONCHOPHONY 157 

of lung from either pleuritic effusion, the accumulation 
of air in the pleural cavity or the pressure of a tumor, 
collapse of pulmonary lobules, coagulation of blood 
within the air vesicles, and sometimes in neoplasm of 
lung. 

For the production of bronchophony, a less degree 
of solidification is requisite than for the production of 
bronchial or tubular respiration. Hence, broncho- 
phony may be associated with a bronchovesicular, 
as well as with a purely bronchial, respiration. This 
is illustrated in the resolving stage of pneumonia. 
When resolution has progressed sufficiently for the 
bronchial to give place to the bronchovesicular respi- 
ration, well-marked bronchophony is often found to 
continue, ceasing at a later period in the resolving 
stage. 

The apparent nearness to the ear of the vocal sound 
in bronchophony is wanting if a certain quantity of 
liquid intervene between the solidified lung and the 
walls of the chest at the situation auscultated. The 
voice under these conditions seems to be more or less 
distant. This difference is readily appreciated. With 
this apparent distance of the bronchophonic voice in 
some instances is associated the modification w^hich is 
characteristic of another sign — namely, egophony. 

WHISPERING BRONCHOPHONY. 

The characters of this sign correspond to those of 
the expiratory sound in the bronchial or tubular 



158 AUSCULTATION IN DISEASE 

respiration {vide p. 127). The sound is more or less 
intensified, high in pitch, and tubular in quality. If 
the patient pronounce numerals in a forced whisper, 
the characters are generally more marked than in the 
expiratory sound in forced breathing. The signifi- 
cance of this sign is usually the same as that of the 
bronchial or tubular respiration, and of bronchophony 
with the loud voice. 

In the diagnosis of enlarged bronchial glands in 
children D'Espine has recently drawn attention to the 
significance of this sign when present below the spine 
of the seventh cervical vertebra. Howell found that 
the bronchial whisper over the cervical vertebrae 
usually persisted to the second or third dorsal spines 
in infancy, that at six years it was inaudible at the 
second dorsal spine in 40 per cent., and at twelve years 
in 85 per cent, of normal children. He concluded that 
bronchial whisper at or below the third dorsal spine 
is valuable evidence of enlarged bronchial glands. 
(W. W. Howell, Am. Jour. Bis. Child., 1915, xx, 90.) 

EGOPHONY. 

This sign is a modification of bronchophony. As 
regards concentration and pitch, it has the characters 
of bronchophony, the distinctive features being appa- 
rent distance from the ear, the tremulousness or a 
nasal, bleating tone. From the latter the name is 
derived, the term signifying the cry of the goat. The 
characters which distinguish the sign from broncho- 



VOCAL RESONANCE AND FREMITUS 159 

phony are readily enough appreciated, and it represents 
a physical condition added to solidification of lung. 
This physical condition is the presence of liquid effu- 
sion. The sign is rarely present in cases of large 
effusion. It occurs usually when the chest is about 
half-filled with liquid, and the lung at the level of the 
liquid is sufficiently condensed to give rise to broncho- 
phony. This condition, under these circumstances, 
involves relaxation of lung above the portion condensed 
by pressure. The sign also sometimes occurs in cases 
of pleuropneumonia, the solidification in these cases 
being due to pneumonic exudation. As a sign of liquid 
effusion it possesses diagnostic value, although, owing 
to the fact that the existence of effusion is easily deter- 
mined by other signs, it may be said to be superfluous. 
When the person examined speaks with the teeth 
approximated, bronchophony has somewhat the char- 
acter of egophony. 

INCREASED VOCAL RESONANCE AND 
FREMITUS. 

The distinctive character of this sign is an increase 
of the intensity of the resonance without notable 
change in other respects. The resonance is still dis- 
tant, diffused, and comparatively low in pitch; in other 
words, the characters distinctive of bronchophony are 
wanting. 

Increased vocal resonance occurs when the lung 
is solidified, the solidification not sufficient in degree 



160 AUSCULTATION IN DISEASE 

to produce bronchophony. Lting slightly or mod- 
erately solidified gives rise to an increase of the inten- 
sity of the resonance of the voice; if the sohdification 
becomes considerable or complete, bronchophony 
takes the place of the simple increase of intensity. 
Thus, at an early period in pneumonia, increased vocal 
resonance precedes bronchophony; and in the stage 
*of resolution the reverse of this takes place — namely, 
increased vocal resonance follows bronchophony, the 
latter ceasing when resolution has progressed to a 
certain extent. 

Contrary to what would perhaps be anticipated in 
the instances just cited, the intensity of the sound, 
when bronchophony is present, may be sometimes 
diminished below that of health, that is, in the first 
stage of pneumonia the increased intensity may cease 
when bronchophony occurs, and return when broncho- 
phony disappears. 

Increase of the vocal resonance occurs in connection 
with pulmonary cavities. Over a cavity of considerable 
size, situated near the superficies of the lung, the 
vocal resonance is sometimes extremely intense, 
without any bronchophonic characters. If broncho- 
phony be present, it denotes considerable solidification 
either around the cavity, or between it and the walls 
of the chest. From the presence or ^the absence of 
bronchophonic characters combined with greatly 
increased intensity of resonance, the auscultator can 
judge whether the cavity be, or be not, in proximity 
to considerable solidification of lung. 



VOCAL RESONANCE AND FREMITUS 161 

Besides the cavernous stage of phthisis, the sign 
is of diagnostic importance in the different affections 
which involve moderate or slight solidification of 
lung — namely, pneumonia early in the disease and in 
the stage of resolution, phthisis, over the compressed 
lung in pleurisy with moderate effusion, collapse of 
pulmonary lobules, hemorrhagic infarcts, and neo- 
plasms of lung. Into the diagnosis of all these 
affections, both bronchophony and increased vocal 
resonance enter; the former when solidification is 
considerable or complete, and the latter when it is 
slight or moderate. 

Increased vocal resonance is especially valuable in 
the diagnosis of early or incipient phthisis. An 
abnormal resonance, however slight, at the summit 
of the chest on one side, is an important sign in that 
affection. In determining an abnormal resonance on 
the right side, either of the summit or elsewhere, 
allowance must always be made for the normally 
greater resonance on this side. 

Increased vocal resonance has the same import as 
hronchovesicular respiration. These two signs, how- 
ever, are not always in the same proportion, that is, 
the characters of the latter may be marked, out of 
proportion to the amount of the increase of the vocal 
resonance, and xice versa. 

Increased vocal fremitus generally accompanies 
increased vocal resonance, and it denotes solidifica- 
tion of lung. Fremitus, however, and resonance are 
not always in equal proportion, that is, either may 
11 



162 AUSCULTATION IN DISEASE 

be increased more than the other. An increased 
fremitus is sometimes of value in the diagnosis of 
phthisis. The greater fremitus on the right side of 
the chest is always to be borne in mind, and due 
allowance is to be made for this normal disparity. 



INCREASED BRONCHIAL WHISPER. 

The significance of this sign is the same as that 
of increased vocal resonance and the bronchovesicular 
respiration; it represents the same physical condition 
as the two latter signs — namely, solidification of lung, 
greater or less, but below the degree requisite to give 
rise to bronchophony and bronchial respiration. Its 
diagnostic application is therefore involved in the 
same pulmonary affections. 

The characters of the sign are those which belong 
to the expiratory sound in the bronchovesicular 
respiration. They consist, therefore, of increase of 
intensity, a quality more or less tubular, and the 
pitch raised, these modifications varying in degree, 
between the slightest appreciable change, and a close 
approximation to the bronchophonic whisper. The 
modifications in degree correspond to the degree of 
solidification. To appreciate the characters of this 
sign it must be studied in comparison with those 
of the normal whisper in different portions of 
the chest. The most important of the diagnostic 
applications of the sign is in cases of phthisis in its 



■i^b, 



INCREASED BRONCHIAL WHISPER 163 

early stage. In this application the points of normal 
disparity between the two sides of the chest at the 
summit are to be borne in mind^ and due allowance 
made for them {vide p. 117). 

A greater intensity of the bronchial whisper at 
the right than at the left summit is not evidence of 
disease; but greater intensity at the left summit is 
always abnormal. As a rule the pitch of the normal 
whisper at the left is higher than that at the right 
summit. In doubtful cases, with greater intensity 
of whisper at the right apex, elevation of pitch is 
indicative of disease. For the significance of whisper 
over the upper dorsal vertebrse, D'Espine's sign, see 
page 158. 

■ Cavernous Whisper. — The characters distinctive of 
the cavernous whisper are those of the expiratory 
sound in the cavernous respiration — namely, lowness 
of pitch, and the quality blowing. The intensity is 
variable. It is limited to a circumscribed space 
corresponding to the situation and size of the cavity. 
Not infrequently the characters of the sign are brought 
into contrast with those of whispering bronchophony 
or increased bronchial whisper; these latter signs exist- 
ing in close proximity, and representing solidification 
of lung in the immediate neighborhood of the cavity. 

Pectoriloquy. — In pectoriloquy, not merely the voice, 
but the speech, is transmitted through the chest; the 
auscultator recognizes words uttered by the patient. 

The student, however, must not expect to be able 
to carry on a conversation with the patient by means 



164 AUSCULTATION IN DISEASE 

of the stethoscope. Often single words only can be 
recognized. To make sure that these are transmitted 
through the chest, care must be taken to exclude 
their direct transmission from the patient's mouth, 
and the auscultator should not know beforehand the 
words which are to be spoken. If these rules be not 
observed, the auscultator may err in supposing that 
the words are transmitted through the chest. When 
auscultation is practised with one ear, the other should 
be closed. 

The speech with either the loud or the whispered 
voice may be transmitted, the latter, distinguished 
as whispering pectoriloquy, being much more 'frequent 
than the former; moreover, in determining whispering 
pectoriloquy, there is less liability to error in mistak- 
ing the perception of words coming directly from the 
mouth for transmission through the chest. In the pro- 
duction of this sign much depends on the distinctness 
with which words are articulated by the patient. 
Normal pectoriloquy at the anterior superior portion 
of the chest is sometimes observed. 

Pectoriloquy belongs among the cavernous signs; 
but it is by no means exclusively the sign of a cavity; 
the speech may also be transmitted by solidified lung. 
It is easy to determine in any case whether the sign 
denotes a cavity or solidified lung. If, with trans- 
mitted speech, the voice has the characters of bron- 
chophony, the sign represents solidification of lung; 
if, on the other hand, the characters of bronchophony 
be wanting, the sign represents a cavity. 



INCREASED BRONCHIAL WHISPER 165 

Amphoric Voice or Echo. — This sign is identical in 
character with amphoric respiration, with which it 
is usually associated {vide p. 144). The production 
of both depends upon the resonator action of a large 
air cavity by which both fundamental and particularly 
overtones are intensified and prolonged. The amphoric 
intonation may accompany the loud voice and the 
whisper; generally it is more appreciable or marked 
with the latter. Its significance is the same as that 
of amphoric respiration. As a rule it represents 
the conditions in pneumothorax — namely, a large 
space filled with air and perforation of lung. In this 
affection it is associated with other signs which suffice 
for a prompt and positive diagnosis. It is not invari- 
ably found in pneumothorax, and it may be present 
in a case at one time and wanting another time; its 
production being dependent on the perforation being 
freely open, and on the bronchial tubes leading to the 
perforation being unobstructed. When not associated 
with other signs which are diagnostic of pneumothorax, 
it denotes a phthisical cavity of- considerable size. 
It is not infrequently a sign of a phthisical cavity 
with rigid walls and communicating freely with 
bronchial tubes. 

The amphoric sound sometimes is observed to follow 
the oral voice; hence the name amphoric echo. 

Diminished and Suppressed Vocal Resonance. — Dimi- 
nution or suppression of the normal vocal resonance 
occurs especially when the pleural cavity contains either 
liquid or air. Whenever the lungs are not in contact 



166 AUSCULTATION IN DISEASE 

with the walls of the chest, the vocal resonance, as 
a rule, is either notably lessened or wanting. The 
sign is, therefore, of value in diagnosis in cases of 
pleurisy with effusion, empyema, hydrothorax, and 
pneumothorax. When the pleural cavity is partially 
filled with liquid, there is diminution or suppression 
of the resonance from the level of the liquid down- 
ward, and generally, just above the level of the 
liquid, the resonance is increased, owing to condensa- 
tion of the lung. The sign is well illustrated by the 
contrast in such cases above and below the level of 
the liquid. As a rule moderate changes of the level 
of the liquid with changes in position of the body may 
be as well demonstrated by means of vocal resonance 
as by percussion. Exceptionally, however, this rule is 
not available. 

The vocal resonance may be diminished or sup- 
pressed when the lung is completely solidified in the 
second stage of pneumonia, if the consolidation 
involves the bronchi, resulting in their obstruction 
(massive consolidation) ; in pulmonary edema and over 
the site of an intrathoracic tumor, abscess or cyst. 

If the vocal resonance be normal, that is, neither 
increased nor diminished, we are warranted in exclud- 
ing all the affections which have been named; the 
exceptional instances are so rare that, practically, 
they may be disregarded. 

In emphysema and in chronic pleurisy with marked 
thickening of the parietal or visceral pleura, or of 
both, due to organized fibrin and connective tissue, we 



INCREASED BRONCHIAL WHISPER 167 

find marked instances of diminished and suppresed 
vocal resonance. 

The normal disparity between the two sides of the 
chest is to be borne in mind with reference to dimin- 
ished or suppressed, as well as to increased, vocal 
resonance; otherwise the relative feebleness of the 
resonance on the left side in health might be con- 
sidered to be morbid. The normally greater reso- 
nance on the right side renders it easier to determine 
a morbid diminution on this than on the left side. 

If the stethoscope be firmly pressed upon the lower 
part of the chest wall, especially in front, above the 
lower border of the lung, there may be a great sup- 
pression or even total absence of vocal resonance. 
The vibration of the chest wall, particularly in the 
lower part, is easily interfered with by a too firm 
pressure of the stethoscope bell upon the chest. 

Diminished and Suppressed Vocal Fremitus. — This 
tactile sensation, which is appreciable in ausculta- 
tion, as a rule, is increased, and diminished or sup- 
pressed, under the same physical conditions which 
occasion corresponding modifications of the vocal 
resonance. Usually the abnormal 'modifications of 
resonance and fremitus go together, but either may be 
out of proportion to the other. The signs relating to 
fremitus thus corroborate those relating to resonance. 

Diminished or suppressed fremitus is valuable in the 
diagnosis of pleurisy with effusion, empyema, hydro- 
thorax, pneumothorax, emphysema, and chronic thick- 
ened pleura. It is, however, to be noted that in 



168 AUSCULTATION IN DISEASE 

exceptional instances the fremitus persists over the 
site of hquid within the chest. 

With regard to vocal fremitus, as to vocal reso- 
nance, it is essential to remember the normal disparity 
between the two sides of the chest, the greater rela- 
tive fremitus being normally on the right side. 

Metallic Tinkling. — This sign has the same char- 
acters when it accompanies either the loud or whis- 
pered voice, as when it is heard with respiration, 
and, of course, it has the same significance (vide p. 
186). It may be more marked with acts of speaking 
than with the respiratory acts. 

SIGNS OBTAINED BY ACTS OF COUGHING 
OR TUSSIVE SIGNS. 

Acts of coughing may be made subservient to 
auscultation of respiratory sounds in two ways: (1) 
By the removal of temporary obstruction from the 
accumulation of mucus within bronchial tubes. If 
the respiratory murmur be diminished or suppressed 
over a portion of the whole of one side of the chest, 
sometimes an act of coughing effects dislodgement 
of a mass of mucus from either a primary bronchus 
or one of its subdivisions, and the normal murmur 
is at once restored. The dependence of the morbid 
sign upon a temporary obstruction is thus demon- 
strated. (2) By an act of coughing more air is expelled 
than by an ordinary expiration, and in the following 
inspiration the vesicles have a wider range of expan- 



ACTS OF COUGHING OR TUSSIVE SIGNS 169 

sion, giving rise to a proportionately loud inspiratory 
sound; hence the characters of this sound are pro- 
nounced and can be better studied. For these two 
objects it is often advisable to request the patient 
to cough with a certain degree of force. 

This procedure of having the patient cough at the 
end of an expiratory act and immediately breathe 
in freely is of particular advantage in eliciting the 
elusive fine crepitations at the apices of the upper or 
lower lobes in suspected or early pulmonary tubercu- 
losis. Care must be taken that the patient does not 
swallow after the cough, as the deglutition sounds are 
readily mistaken for adventitious sounds arising in the 
lungs. 

Acts of coughing, moreover, give rise to ausculta- 
tory signs which have their analogues in signs obtained 
by respiration and the voice. When the conditions are 
present which are represented by bronchial respiration, 
bronchophony and the bronchophonic whisper, sounds 
are obtained which correspond to these in their char- 
acters. The cough is then said to be bronchial. With 
the stethoscope applied over an empty cavity of some 
size, situated near the surface of the lung, the ear 
receives with acts of coughing a concussion or shock 
which is sometimes so forcible as to be painful. This 
corresponds to an intense vocal resonance. Limited 
to a circumscribed space, it is a highly significant 
cavernous sign. It may be present when the cavernous 
respiration is wanting. A low-pitched, blowing sound 
corresponds to the expiratory sound in the cavernous 



170 AUSCULTATION IN DISEASE 

« 

respiration and the cavernous whisper. An amphoric 
intonation may be heard with acts of coughing which 
corresponds to amphoric respiration and amphoric 
voice. This sign is sometimes more marked with 
cough than with the breathing and voice. Cavernous 
gurghng may also be obtained more distinctly with 
cough than with respiration. Finally, metallic tinkling 
not infrequently accompanies acts of coughing. 

ADVENTITIOUS RESPIRATORY SOUNDS, OR RALES. 

Adventitious respiratory sounds, or rales, are dis- 
tinguished from the morbid signs already considered, 
by the fact that they have no analogues in health; 
in other words, they are not normal sounds abnormally 
modified, but wholly new sounds. They are usually 
classified as : (a) Dry rales, which are produced by the 
presence of thick tenacious exudations within the 
bronchial tubes or by muscular spasm of the tubes; 
and (6) moist rales, due to the presence of liquid. 
These primary groups are then subdivided according 
to the different anatomical situations in which they 
are produced, as follows: (1) Laryngeal and tracheal 
rales; (2) bronchial rales; (3) vesicular rales; (4) 
cavernous rales; (5) pleural rales; (6) indeterminate 
rales. 

Laryngeal and Tracheal Rales. — ^The rales produced 
within the larynx and trachea may be either moist 
or dry. The moist or bubbling sounds are produced 
when mucus or other liquid accumulates in these sections 



ADVENTITIOUS RESPIRATORY SOUNDS 171 

of the air tubes. This occurs frequently in the mori- 
bund state, and the sounds are then known as the 
"death rattles." When not incident to this state, 
they denote either insensibility to the presence of 
liquid, as in coma, or inability to effect the removal 
of the liquid by acts of expectoration. The sounds 
are heard at a distance. They exemplify, on a large 
scale, moist or bubbling auscultatory sounds which 
are produced within the bronchial tubes. Dry sounds 
produced within the larynx or trachea are caused by 
spasm of the glottis, and by diminution of the calibre, 
either at or below the glottis, from edema, exuda- 
tion, the presence of a foreign body, or the pressure 
of a tumor. The dry sounds are distinguished as 
whistling, wheezing, crowing, whooping, etc. They 
are heard at a distance, and they also exemplify aus- 
cultatory sounds representing analogous conditions in 
the bronchial tubes. Characteristic sounds, produced 
at the glottis by spasm, enter into the diagnosis of 
certain affections — namely, laryngismus stridulus, per- 
tussis, croup, and aneurism involving excitation of 
the recurrent laryngeal nerve. Other sounds are due 
to paralysis of the laryngeal muscles. Again, dry 
sounds produced by stenosis of the trachea from the 
pressure of an aneurismal or other tumor, cicatrization 
of ulcers, and morbid growths, are of diagnostic impor- 
tance. Although audible without auscultation, these 
different sounds, with reference to the precise situa- 
tion at which they are produced, may sometimes 'be 
studied with advantage by means of the stethoscope. 



172 AUSCULTATION IN DISEASE 

They are embraced under the name stridor. The 
respiration, voice, and cough, when accompanied by 
these sounds, are said to be stridulous. 

MOIST BRONCHIAL RALES. 

The moist bronchial rales are bubbling sounds 
produced in different branches of the bronchial tree. 
They are sounds of which the "tracheal rattles" are 
an exaggerated type. They may be imitated by 
blowing into liquids through tubes differing in size. 
They may also be produced in the lungs of the sheep 
or the calf, after removal from the body, by injecting 
into the bronchi glycerin or some other liquid, and 
imitating the respiratory acts by means of a pair of 
bellows, auscultation being practised with the stetho- 
scope applied upon the surface of the lung, or with 
several thicknesses of cloth intervening. The bubbles 
seem to be large or small according to the size of the 
bronchial tubes in which they produced. Apparent 
differences in the size of the bubbles are distinguished 
by the names coarse and fine. In the primary and 
secondary bronchial branches the moist sounds are 
relatively quite coarse; they are less so in tubes of 
the third or fourth dimensions; in smaller tubes they 
become fine, and in those of minute size they become 
extremely fine. 

Extremely fine bubbling sounds constitute what has 
been known as the suhcrepitant rale, so-called because 
it approaches in character to the crepitant rale, pro- 



MOIST BRONCHIAL RALES 173 

duced within the air vesicles and bronchioles. We 
may thus judge of the size of the bronchial tubes in 
which the rales are produced by their comparative 
coarseness or fineness. Frequentl}^ however, coarse 
and fine rales are intermingled, and generally, those 
which are either coarse or fine are not uniform, but 
appear to be of unequal size. In all the varieties of 
the moist bronchial rales the bubbling character of the 
sounds is sufficiently distinctive for their recognition. 
The differentiation of the so-called subcrepitant from 
the crepitant rale alone involves some nice points of 
distinction. 

Coarse bubbling rales sometimes occur in acute 
bronchitis affecting the larger bronchial tubes. Their 
occurrence is exceptional, because, in general, the 
mucus within the tubes does not accumulate suffi- 
ciently and is too consistent for the production of 
bubbling sounds. These rales occur in cases in which 
the mucus is unusually thin, and either more abun- 
dant than usual, or an accumulation takes place in 
consequence of inability to expectorate freely. These 
conditions are wanting in the majority of the cases 
of ordinary acute bronchitis. A mucopurulent liquid 
in cases of chronic bronchitis is better suited for the 
production of bubbling sounds than simple mucus. 
Moreover, coarse rales are heard oftener in children 
than in adults, because the former do not voluntarily 
expectorate as freely as the latter. Serous transuda- 
tion (bronchorrhea) into tubes of large size may give 
rise to coarse bubbling rales, and also the presence of 



174 AUSCULTATION IN DISEASE 

blood in some cases of profuse hemorrhage. In bron- 
chitis and bronchorrhea the rales are heard on both 
sides of the chest. The bubbling rales, whether 
coarse or fine, are heard either with the act of inspira- 
tion or of expiration, or with both acts. 

Fine bubbling sounds and the so-called subcrepi- 
tant rale occur in various pathological connections. 
The characters of the latter are to be borne in mind 
with reference to the discrimination from the crepi- 
tant rale. The most distinctive character is the 
moist sound or bubbling; this is sufficiently appre- 
ciable. Other characters are their occurrence fre- 
quently, in expiration as well as in inspiration, and the 
inequality of the fine bubbling sounds. 

The so-called subcrepitant rale, existing over the 
chest on both sides, is diagnostic of bronchitis affect- 
ing the smaller bronchial tubes (capillary bronchitis), 
when taken in connection with other signs, and the 
symptoms. The rales exist on both sides, because 
this, as well as bronchitis affecting the larger tubes, 
is a bilateral affection. The sign is of great prac- 
tical value in the diagnosis of that variety of bron- 
chitis. The rale also occurs on both sides, and is 
more or less diffused in pulmonary edema. The 
connection with the latter affection is shown by the 
associated physical signs, together with the symp- 
toms. In so-called capillary bronchitis the bubbling 
is due to the presence of thin mucus, and in pulmo- 
nary edema to serous transudation within the small 
bronchial ramifications. 



MOIST BRONCHIAL RALES 175 

Fine bubbling or the so-called subcrepitant rale has 
other pathological connections, as follows: 

1. It occurs in lobar pneumonia during the stage 
of resolution. Here it is due to the presence of mucus 
from a bronchitis limited to the affected lobe or lobes, 
and, in a measure, to liquefied pneumonic exudation. 
It is considered as denoting commencing and pro- 
gressing resolution in pneumonia. Sometimes it is 
intermingled with rales which are more or less coarse. 

2. In circumscribed pneumonia, hemorrhagic infarc- 
tus, and pulmonary apoplexy, the fine or subcrepitant 
rale, often associated with those which are more or 
less coarse, denotes the presence of mucus or of blood 
within the bronchial tubes. The rales are localized 
in space, or in spaces, corresponding to the situation 
and extent of the affection. 

3. During and shortly after a hemoptysis, fine 
rales limited to a particular situation are sometimes 
heard, proceeding from blood in the small bronchial 
tubes, and indicating the situation of the hemorrhage. 

4. A purulent liquid admits of bubbling much more 
readily than mucus; hence, in cases of chronic bron- 
chitis with an expectoration of pus, fine and coarse 
bronchial rales are more frequent than in acute bron- 
chitis. Pus also, may be present within bronchial 
tubes of small size, not as a product of bronchitis, 
but from the evacuation of an abscess of either the 
pulmonary parenchyma, of the liver, or some other 
adjacent part, and from perforation of lung in some 
cases of empyema. 



176 AUSCULTATION IN DISEASE 

5. In the different stages of phthisis moist bron- 
chial rales are usually present. The liquid in the 
tubes, if the disease be advanced, is derived, in part, 
from associated bronchitis, and, in part, from lique- 
fied tuberculous exudation. The bubbling sounds may 
be more or less coarse or fine, and both are often 
intermingled. Early in the disease, before softening 
of the exudation has taken place, fine bubbling, or 
the subcrepitant rale, limited to the summit of the 
chest, is an important diagnostic sign. This fine 
subcrepitant rale in early pulmonary tuberculosis is 
heard also, and not infrequently, at the tip of the 
lower lobes behind, in the interscapular regions. It 
belongs among the accessory physical signs On which 
the diagnosis may depend. Here the liquid is derived 
from a coexisting circumscribed bronchitis. 

In cases of fibroid phthisis, or cirrhosis of lung, 
moist rales, coarse and fine, are generally more or 
less abundant and diffused over the whole, or the 
greater part, of the chest on the affected side. 

In the foregoing account of the moist bronchial 
rales the subcrepitant rale is not reckoned as a sign 
distinct from fine bubbling sounds. Inasmuch as the 
mechanism and the significance are the same, and it 
is not easy to draw a line of demarcation between 
the two, the distinction is unimportant. It is suffi- 
cient to bear in mind that very fine bubbling sounds 
are called subcrepitant, because they are somewhat 
analogous to the crepitant rale. The points which 
distinguish the latter are, however, well marked, as 



MOIST BRONCHIAL RALES 177 

will appear when the characters of that sign are 
considered. The term subcrepitant gives rise to con- 
fusion, and there is no advantage in retaining it as the 
name of a distinct sign. Very fine bubbling expresses 
more correctly the characters of the sign. The moist 
rales are often called mucous rales. This name is 
obviously inappropriate, since not only are the sounds 
produced by other liquids than mucus, but other 
liquids are best suited for their production, especially 
in the large and medium-sized tubes. 

The several varieties of the moist bronchial rales 
may be produced by the injection of a liquid in vary- 
ing quantity into the bronchi of the lungs removed 
from the body of an animal of sufficient size, e. g., 
of the sheep or calf, and imitating respiration by 
means of bellows. 

The moist bronchial rales, whether coarse or fine, 
vary in pitch accordingly as the lung surrounding 
the tubes in which they are produced is or is not 
solidified. If the lung he solidified, the pitch is high; 
if there he no solidification, the pitch is comparatively 
low. Thus the pitch of the rales is high in the second 
stage of pneumonia and in phthisis with considerable 
solidification, whereas the pitch is low in bronchitis 
and pulmonary edema. If, therefore, the respiratory 
sound be suppressed, it is easy to determine by the 
pitch of these rales whether the lung be solidified or 
not, and to judge measurably of the degree of solidi- 
fication. Attention to the pitch in connection with 

these rales is sometimes of value in diagnosis. 
12 



178 AUSCULTATION IN DISEASE 

DRY BRONCHIAL RALES. 

All adventitious sounds which are not moist, pro- 
duced within the air tubes below the trachea, are 
embraced under the name dry bronchial rales. The 
sounds are many and varied in character. They are 
often musical notes. Frequently they are sugges- 
tive of certain familiar sounds, such as the chirping 
of birds, the cry of a young animal, snoring in sleep, 
cooing of pigeons, humming of the mosquito, the- 
note of the violoncello, etc. They are often heard 
at a distance, and characterized as wheezing sounds. 
An interrupted or clicking sound is not uncommon. 

All these varieties are practically unimportant, and 
it would be a needless refinement to consider par- 
ticular varieties as distinct signs. The only dis- 
tinction which it is desirable to make is into the 
sibilant and sonorous rales. This distinction is based 
on difference in pitch; sibilant rales are high, and son- 
orous rales are loiv in pitch. As a rule the sibilant rales 
are produced in the small and the sonorous rales in 
the larger sized bronchial tubes. The sounds may 
accompany either inspiration or expiration, or both. 
The sibilant and sonorous rales are often intermingled. 
There may be sibilant rales with inspiration, and 
sonorous rales with expiration, within the same situa- 
tion. Moreover, these rales are found often to vary 
from minute to minute, being at one instant sibilant, 
and at another sonorous. Students are likely to 
confound sonorous rales with bronchial breathing, 
and sometimes with friction sounds. 



DRY BRONCHIAL RALES 179 

The physical condition represented by the dry rales 
is diminished calibre of the air tubes at certain 
points, and especially in consequence of spasm of 
the bronchial muscular fibers. The latter consti- 
tutes the essential pathological condition in a par- 
oxysm of asthma; and in this affection the dry rales 
are always marked. Their diagnostic importance 
relates chiefly to asthma. Both sibilant and sonor- 
ous rales are present and diffused over the entire 
chest. Wheezing sounds with expiration are heard 
by the patient and by others at a distance. A single 
paroxysm of asthma affords an opportunity for the 
student to observe all the varieties and fluctuations 
of these rales. Taken in connection with other signs 
and symptoms, the rales are pathognomonic of asthma. 

More or less spasm of the bronchial muscular fibers 
occurs in certain cases of bronchitis, without being 
sufficiently great and extensive to give rise to a par- 
oxysm of asthma or even any embarrassment of 
respiration. Under these circumstances the rales are 
less marked and diffused. An asthmatic element 
may be said to enter, more or less, into these cases. 
Narrowing of bronchial tubes by tenacious mucus 
which gives rise to no bubbling sounds, and, perhaps, 
unequal swelling of the mucous membrane may also 
occasion sibilant and sonorous rales in bronchitis. 

Dry rales at the summit of the chest are not infre- 
quent in cases of phthisis due to spasm, the presence 
of mucus, or to swelling of the mucous membrane. 
They are sometimes quite annoying to phthisical 
patients. 



180 AUSCULTATION IN DISEASE 

Clicking sounds are suggestive of the sudden sepa- 
ration of tenacious mucus from the walls of the 
bronchial tubes. These are sufficiently common in 
bronchitis and in phthisis. 

VESICULAR OR CREPITANT RALE. 

This is the only vesicular rale. It is usually con- 
sidered to be produced within the air vesicles, but 
probably the terminal bronchial tubes or bronchioles 
participate in its production. 

It is to be distinguished from very fine bubbling 
sounds, or the so-called subcrepitant rale. The points 
of distinction are as follows: The sounds are crack- 
ling, not bubbling in character. They may be defined 
to be very fine crackling sounds. ' This point of differ- 
ence is very distinctive. There are, however, other 
differential points. The crackling sounds are equal, 
whereas, fine bubbling sounds are unequal, that is, 
they give the impression of bubbles of unequal size. 
The crepitating sounds are heard at the end of the 
inspiratory act, and especially at the end of a forced 
inspiration, the subcrepitant rale, on the other hand, 
being heard often with or near the beginning of 
inspiration, and, perhaps, ceasing before the end of 
the inspiratory act. Another distinctive feature is 
the abrupt development of the crepitant rale; there 
is a shower of c!rackles, as it were, at the end of a 
forced inspiration. Finally, the rale is never heard 
in expiration. The apparent exceptions to this state- 



VESICULAR OR CREPITANT RALE 181 

ment are instances in which the crepitant and the 
subcrepitant rale are associated. This is not very 
infrequent, and, with a practical knowledge of the 
characters of each, it is by no means difficult to appre- 
ciate the combination of the two signs. In fact, the 
combination affords an excellent opportunity to 
illustrate the distinctive characters of each; the fine 
bubbling at, or near the beginning of inspiration, 
followed by the fine crackling at the end of this act 
and the former perhaps reproduced in the act of 
expiration. 

There are various modes in which the crepitant 
rale may be imitated; for example, rubbing together 
a lock of hair near the ear, throwing fine salt upon 
live coal or into a heated vessel, igniting a train of 
gunpowder, and alternately pressing and separating 
the thumb and finger moistened with a solution of 
gum arable and held near the ear. A perfect repre- 
sentation is afforded by squeezing a piece of an arti- 
ficial preparation known as the India rubber sponge, 
and observing the sound produced by the separation of 
the walls of the interstices when the piece expands 
from its elasticity. This preparation exemplifies the 
true mechanism of the sign as described, first, by the 
late Dr. Carr, of Canandaigua, N. Y., in an article 
published in the American Journal of Medical Sciences, 
in October, 1842.^ Expansion of the lungs of the 
sheep or calf, after removal from the body, the stetho- 

1 Vide article by the author in the New York Monthly Med. 
Jour, for February, 1869. 



182 AUSCULTATION IN DISEASE 

scope being applied to the lung surface, gives, in cer- 
tain situations, a well-marked crepitant rale. 

The crepitant rale is a common sign in pneumonia. 
It very rarely occurs in any other pathological con- 
nection. Of all respiratory signs, this is most entitled 
to be called pathognomonic. It belongs especially to 
the first stage of acute pneumonia. It is not invari- 
ably present, but it occurs in the majority of cases 
of acute pneumonia. In the second stage, or the 
stage of solidification, the rale generally disappears. 
It not infrequently is reproduced in the stage of reso- 
lution, and it is then called the returning crepitant 
rale. In the latter stage it is often found in com- 
bination with the subcrepitant rale. The practical 
value of this sign relates chiefly to the diagnosis of 
pneumonia. 

It is stated that the crepitant rale is sometimes 
found in cases of pulmonary edema, and during or 
directly after an attack of hemoptysis. If it ever 
occur in these cases, the instances must be extremely 
rare. The statement is perhaps based on the occur- 
rence of the subcrepitant, this being confounded with 
the crepitant rale. It occurs transiently under the 
following circumstances: A patient who has been 
confined for some time in bed, lying on the back, 
and much enfeebled with any disease, if suddenly 
raised to a sitting posture and auscultated, a crepi- 
tant rale is often found on the posterior aspect of the 
chest at the end of a forced inspiration. The rale 
disappears after a few forced inspirations. It is 



CAVERNOUS OR GURGLING RALE 183 

heard, not on one side only, but on both sides. The 
explanation is that during the recumbent posture, 
continued for some time and the patient breathing 
feebly, enough of the air vesicles and bronchioles 
become agglutinated by means of a little sticky 
transudation to give rise to crackling sounds in a 
few forced inspirations. It may be of use to men- 
tion that if the stethoscope be applied to the anterior 
surface of a chest much covered with hair, the move- 
ments of the pectoral extremity of the instrument 
in the act of inspiration may produce a sound identical 
with the crepitant rale. This can be eliminated by 
applying oil or vaseline liberally over the hairy surface. 
A crepitant rale at the summit of the chest, within 
a circumscribed space, is one of the accessory signs 
of phthisis. It denotes a circumscribed pneumonia 
which clinical experience shows to be generally sec- 
ondary to phthisis; hence the diagnostic significance 
of the sign. 

CAVERNOUS OR GURGLING RALE. 

A pulmonary cavity of considerable size, contain- 
ing a certain quantity of liquid, and communicating 
freely with bronchial tubes, furnishes a rale which 
is characteristic. The character of the sound is 
expressed as fully as possible by the term gurgling. 
The sound is produced by large bubbling and the 
agitation of the liquid within the cavity. It may 
be compared to the sound produced by the boiling 



184 AUSCULTATION IN DISEASE 

of a liquid in a flask or large test-tube. The sound 
is sometimes high pitched and amphoric, but gener- 
ally it is low in pitch. It is heard with more or less 
intensity within a circumscribed space, almost invari- 
ably at or near the summit of the chest; but if intense, 
the sound is diffused, and it may be sometimes heard 
at a distance. Its diagnostic importance relates to 
the advanced stage of phthisis. The rale is heard 
chiefly or exclusively in the act of inspiration. It 
may be produced by the act of coughing sometimes 
with greater intensity than by respiration. 

PLEURAL RALES— FRICTION SOUNDS— METALLIC 
TINKLING— SPLASHING. 

The signs embraced under the name pleural rales 
are: (1) Sounds produced by the rubbing together 
of the pleural surfaces, and hence called friction 
sounds; (2) metallic tinkling; (3) splashing or succus- 
sion sounds. 

Friction Sounds. — ^Movements of the pleural sur- 
faces upon each other take place in inspiration and 
expiration; but in health these movements occasion 
no sound. Sounds are produced when the surfaces 
are covered with a recent fibriilous exudation which 
prevents the normal continuous, unobstructed move- 
ments. 

The sounds are generally interrupted, that is, two, 
three, or more sounds occur during the act of inspiration 
or expiration, or during both acts. The intensity of the 



PLEURAL RALES— METALLIC TINKLING 185 

sounds varies much in different cases. A slight grazing 
sound only may be heard, or, on the other hand, the- 
sounds may be so loud as to be heard by the patient, and 
by others at a distance. The character of the sounds 
is variable. The slight rubbing or grazing character 
may be imitated by placing over the ear the palmar 
surface of one hand, and moving over its dorsal sur- 
face slowly the pulpy portion of a finger of the other 
hand. In some instances, however, the rough char- 
acter of the sounds is expressed by such terms as 
rasping, grating, and creaking. In these instances 
the sounds denote density of the morbid product 
which roughens the pleural surfaces. In connection 
with very rough sounds, vibration of the walls of the 
chest, or fremitus, is sometimes perceived by palpation. 

Aside from the character of the sounds as just 
stated, they are distinguished by their apparent near- 
ness to the ear; they seem sometimes to be produced 
upon the surface of the chest. They are sometimes 
intensified by firm pressure of the stethoscope upon 
the chest. After a little practical knowledge of these 
sounds they can hardly be confounded with any 
other rales. 

Pleuritic friction sounds generally denote pleurisy. 
In cases of pleurisy with effusion, slight rubbing or 
grazing is sometimes heard before much liquid accu- 
mulates within the pleuritic cavity. The physical 
conditions, however, after the effusion has been 
removed, are much more favorable for the produc- 
tion of friction sounds, and they are often now rough 



186 AUSCULTATION IN DISEASE 

in character. They may be transient, or they may 
continue for a considerable period, their duration 
depending on the arrest of the movements of the 
pleural surfaces by means of either agglutination with 
fibrin, or adhesion from the growth of areolar tissue. 

Pleuritic friction sounds occur not infrequently in ' 
cases of pneumonia, denoting, in this connection, 
coexisting pleurisy. 

Slight rubbing or grazing at the summit of the 
chest is one of the accessory signs of phthisis. It 
denotes a circumscribed, dry pleuHsy, which, as clinical 
experience shows, is generally secondary to phthisis, 
and hence the diagnostic significance of the sign. 

In the foregoing instances in which friction sounds 
are stated to occur, their significance relates to pleurisy. 
In some rare instances the sounds are produced by 
miliary tubercles, or neoplastic nodules projecting 
beyond the plane of the visceral pleural surface, 
without pleuritic inflammation. 

Metallic Tinkling. — This is a vocal as well as a respi- 
ratory sign. It is also produced by acts of coughing, 
and sometimes by the act of deglutition. The name 
expresses the distinctive character of the sign. It 
consists in a series of tinkling sounds of a high-pitched, 
silvery, or metallic tone. The number of sounds 
varies from a single sound to two, three, or more 
sounds, during an act of either inspiration or expi- 
ration. This sign may be imitated in various ways 
by means of an India rubber bag of considerable 
size. Forcing a liquid into the bag with Davidson's 



PLEURAL RALES— METALLIC TINKLING 18? 

syringe, tapping the bag with the finger, or shaking 
it will produce tinkling sounds. The best mode of 
artificial representation of the sign is to connect the 
bag with a flexible tube, the latter containing a few 
drops of liquid, and blowing into the tube so as to 
produce bubbles at the communication of the tube 
with the bag. In this latter experiment it is not 
necessary that the bag contain any liquid. It occurs 
irregularly, that is, it is not present in every act of 
breathing, but is heard at variable intervals. It may 
sometimes be produced by forced, when it is not heard 
in tranquil, breathing. It can only be confounded 
with tingling sounds sometimes produced within the 
stomach. The latter, however, are easily discrimi- 
nated by their situation, and the absence of associated 
signs denoting the affections of the chest in which the 
sign occurs. 

Metallic tinkling is the sign of pneumothorax with 
perforation of lung. In the great majority of the cases 
in which it is found it is diagnostic of this affection. 
It is, however, always associated with other physical 
signs corroborative of the diagnosis. 

It is a rare sign, in cases of phthisis, of a large 
pulmonary cavity, the conditions for its production 
being analogous to those in pneumohydrothorax, 
namely, a space of considerable size containing air, 
the space communicating with bronchial tubes. 

Splashing, or Succussion Sounds. — This sign is pro- 
duced by succussion, which is reckoned as one of 
the different modes of physical exploration. Sounds 



188 AUSCULTATION IN DISEASE 

thus produced are not infrequently heard at some 
distance. Generally, however, succussion is practised 
while the ear is applied to the chest, so that properly 
enough the sign may be embraced among the aus- 
cultatory signs, although not produced by respiration. 

Splashing is pathognomonic of either hydropneumo- 
thorax or pyopneumothorax. It is especially valuable 
as a sign of these affections because it is almost 
invariably available. The instances are extremely 
few in which the sign is wanting when air and liquid 
^e contained in the pleural cavity. It is obtained 
by jerking the body of the patient with a quick, 
somewhat forcible movement, the ear being in contact 
with the chest. 

The sound is like that produced when a bottle 
partially filled with liquid is shaken. The sound is 
often high-pitched and amphoric in quality. The 
only liability to error is in confounding with this 
sign splashing produced within the stomach. Atten- 
tion to other signs will always protect against this 
error. 

Indeterminate Rales. — Under this head may be 
embraced some sounds sufiiciently recognizable, but 
indeterminate as regards the rationale of their pro- 
duction and the physical conditions which they 
represent. They may be designated crumpling and 
crackling sounds. The former are probably due to 
pleuritic rubbing, and the latter to the separation 
of some slightly adherent air vesicles or bronchioles. 
Their diagnostic value relates only to the early stage 



PLEURAL RALES— METALLIC TINKLING 189 

of phthisis. In conjunction with other signs, any 
indeterminate rale, if Hmited to the summit of the 
chest, and especially to one side, has some weight in 
the diagnosis. Crumpling and crackling sounds, how- 
ever, are not uncommon in healthy persons at the end 
of forced inspiration. The fact of their presence at 
both summits, and the absence of other morbid 
signs, are the grounds for not considering them as 
evidence of disease. They are found in health, 
especially if the binaural stethoscope be employed. 
Their diagnostic significance, thus, depends on limi- 
tation to the summit of the chest on one side, and 
association with other signs pointing to incipient 
phthisis. 



CHAPTER VII. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF 
THE RESPIRATORY ORGANS. 

Affections of the larynx and trachea — Bronchitis seated in 
large bronchial tubes — Bronchitis seated in small bronchial 
tubes, or capillary bronchitis — Collapse of pulmonary lobules — 
Lobular pneumonia — Asthma — Pulmonary or vesicular emphy- 
sema — Pleurisy, acute and chronic — Empyema — Hydrothorax 
— Pneumothorax — Hydropneumo thorax — Pyopneumothorax — 
Acute lobar pneumonia — Circumscribed pneumonia — Embolic 
pneumonia — Hemorrhagic infarctus — Pulmonary apoplexy — 
Pulmonary gangrene — Pulmonary edema — Neoplasms of lung 
— Tumor within the chest — Acute miliary tuberculosis — Pul- 
monary phthisis — Fibroid phthisis — Interstitial pneumonia, or 
cirrhosis of lung — Diaphragmatic hernia. 

In the preceding chapters we have considered the 
abnormal physical conditions incident to morbid 
changes in the respiratory tract. The effect of these 
pathological physical conditions upon the physical 
signs has been studied; and the distinctive characters 
of each physical sign have received particular attention, 
in order that the abnormal signs may be recognized. 

The object of this chapter is to group together the 
physical conditions in the different diseases of the 
respiratory system, with the representative signs 
on which rests the physical diagnosis of each of the 



AFFECTIONS OF THE LARYNX AND TRACHEA 191 

diseases. The scope of this manual is limited to the 
physical diagnosis of these affections; but the fact is 
not to he lost sight of that in practical medicine physical 
signs are not to be disassociated from symptoms and 
pathological laws. An exclusive reliance on physical 
signs would lead to errors in diagnosis, although, 
doubtless, errors more important and more frequent 
necessarily occur when the practitioner ignores per- 
cussion and auscultation. The signs furnished by 
percussion and auscultation only have been thus far 
considered, but in grouping these in this chapter 
signs obtained by other methods of physical explora- 
tion will be embraced in so far as they enter into the 
diagnosis of the different diseases of the respiratory 
system. These different diseases will be taken up 
separately with the exception of those seated in the 
larynx and trachea. With reference to physical signs, 
the laryngeal and tracheal affections may be consid- 
ered collectively. 

AFFECTIONS OF THE LARYNX AND TRACHEA. 

The physical signs referable to the chest in dis- 
eases of the larynx and trachea denote more or less 
obstruction to the free passage of air through these 
sections of the air tubes. The obstruction in the 
different diseases involves different pathological con- 
ditions. Spasm of the glottis is one of these conditions, 
constituting the affections known as laryngismus 
stridulus and spasmodic croup, occurring also as a 



192 DISEASES OF THE RESPIRATORY ORGANS 

pathological element in laryngitis, and sometimes in 
connection with aneurism, or a tumor of some kind 
involving the recurrent laryngeal nerve. Another 
pathological condition is the opposite of this, namely, 
paralysis of the muscles of the glottis, the vocal cords 
remaining flaccid and approximating during inspira- 
tion. Other pathological conditions are edema of 
the glottis, swelling of the membrane at the glottis 
in laryngitis, together with, in the adult, submucous 
infiltration, diphtheritic exudation, cicatrization of 
ulcers, morbid growths, and the presence of foreign 
bodies. 

In the affections involving the foregoing patho- 
logical conditions percussion and auscultation are of 
use: (1) By enabling the physician to exclude all 
diseases within the chest. The absence of signs show- 
ing the existence of pulmonary diseases renders it 
certain that the symptoms denoting embarrassment 
of respiration are referable to the larynx or trachea. 
(2) By means of auscultation the amount of obstruc- 
tion may be determined more accurately than by the 
subjective symptoms. The amount of obstruction is 
represented by a proportionate weakening of the vesic- 
ular murmur. This is more reliable as regards deter- 
mining a dangerous amount of obstruction than the 
sense of the want of air or the suffering of the patient. 
The degree of diminution of the vesicular murmur 
is determinable with more accuracy the better the 
auscultator is acquainted with the normal intensity, 
that is, the intensity prior to the occurrence of obstruc- 



AFFECTIONS OF THE LARYNX AND TRACHEA 193 

tion. With this knowledge the weakening of the 
murmur is a correct criterion of the amount of obstruc- 
tion. In all the pathological conditions named the 
respiratory murmur is more or less diminished in 
intensity on both sides of the chest; there are no signs 
obtained by percussion, nor do vocal resonance or 
fremitus offer anything distinctive. 

In cases of considerable or great obstruction during 
inspiration inspection furnishes marked signs. The 
expansion of the chest on both sides is restricted, 
the lower part of the chest is contracted in the act 
of inspiration, and in this act the soft parts above 
the clavicles are depressed. The contrast between 
these abnormal movements and the normal thoracic 
movements of the patient is striking and distinctive. 

An important application of auscultation is the 
localization of a foreign body which has been inhaled. 
If the vesicular murmur on both sides be more or less 
weakened, the foreign body must be situated in either 
the larynx or the trachea. If, on the other hand, 
the vesicular murmur be weakened or suppressed on 
one side, and increased on the other side, the body 
is lodged in a primary bronchus. The importance 
of this application of auscultation before opening 
the trachea to remove a foreign body is sufficiently 
obvious. The situation of a foreign body may be 
changed from one bronchus to the other by an act of 
coughing, even after an operation has been commenced ; 
this is, of course, at once determinable by auscultation. 

By the application of cT-ray examination, especially 
13 



194 DISEASES OF THE RESPIRATORY ORGANS 

when combined with stereoscopic study of the plates, 
invaluable information is to be obtained as to the 
location of foreign bodies within the air passages. 
When available it should be used to supplement 
auscultation and percussion. 

BRONCHITIS SEATED IN LARGE* BRONCHIAL 

TUBES. 

In bronchitis, either acute or chronic, as it is or- 
dinarily presented in practice, the inflammation is 
seated in the large bronchial tubes, in many cases 
probably not extending beyond the primary and 
secondary bronchi. The physical conditions are 
more or less swelling of the mucous membrane (this, 
however, not being sufficient to occasion any notable 
obstruction to the free passage of air) and the pres- 
ence, in different cases, in greater or less quantity, of 
mucus, mucopurulent matter, pure pus, and serum. 

The physical diagnosis involves negative rather than 
positive points; in other words, the diseases from 
which bronchitis is to be differentiated are excluded by 
the absence of their diagnostic signs. These diseases 
are pneumonia, pleurisy, and phthisis. Each of these 
is characterized by the presence of signs, the absence 
of which warrants its exclusion. In bronchitis there 
is no disparity between the two sides of the chest in 
size, symmetry, or mobility; in the resonance obtained 
by percussion, nor in vocal resonance, the bronchial 
whisper, and fremitus. The swelling of the bronchial 



BRONCHITIS IN BRONCHIAL TUBES 195 

mucous membrane may cause some diminution of the 
intensity of the vesicular murmur, but as the affection 
is bilateral and the bronchial tubes on each side are 
affected equally, both in degree and extent, no ap- 
preciable disparity in this respect between the two 
sides is caused by this physical condition. Weakening 
or suppression of the murmur over an area greater or 
less may be caused by bronchial obstruction from a 
plug of mucus. This obstruction is sometimes removed 
by an act of expectoration, after which the murmur 
is found to have returned, or to have regained its 
normal intensity. 

The foregoing points, taken in connection with 
the history and symptoms, suffice for the diagnosis. 
Signs due directly to the disease represent diminished 
calibre of the tubes at certain points from swelling 
of the membrane, adhesive mucus, and spasm of bron- 
chial muscular fibers. These signs are the dry bron- 
chial rales. They are rarely prominent, and are oftener 
absent than present, if the bronchitis be unaccompanied 
by asthma; hence, they are of little value in the diag- 
nosis. Other signs are the bubbling sounds or the 
moist bronchial rales. In acute bronchitis these are 
oftener absent than present. They occur when liquid 
morbid products within the tubes are unusually abun- 
dant, or when the removal of these is with difficulty 
effected by expectoration in consequence of muscular 
debility or other causes. These rales are abundant 
and loud in proportion as the liquid within the tubes 
is either mucopurulent, purulent, or serous in char- 



196 DISEASES OF THE RESPIRATORY ORGANS 

acter. They are more or less coarse in proportion to 
the size of the tubes in which the bubbhng takes 
place. 

The diagnostic points, negative and positive, which 
have been stated, are alike applicable to acute and 
chronic bronchitis, it being, of course, understood 
that the affection is primary, that is, not secondary 
to some other pulmonary disease. 

If the bronchitis be unaccompanied by solidification 
of lung, the moist rales which may be present are 
low in pitch. The pitch is raised and the sounds 
sharper and more crackling if there be solidified lung 
surrounding or adjacent to the tubes in which the 
moist rales are produced. 

BRONCHITIS SEATED IN SMALL BRONCHIAL TUBES 
— CAPILLARY BRONCHITIS — COLLAPSE OF 
PULMONARY LOBULES— LOBULAR PNEUMONIA. 

Inflammation extending into the small tubes (cap- 
illary bronchitis) occasions the same physical conditions 
which are incident to bronchitis affecting tubes of 
large size, namely, swelling of the membrane, and the 
presence of liquid morbid products. The exudates 
are not as easily removed by expectoration as when 
they are within large tubes, and therefore they are 
constantly present in greater or less quantity. These 
conditions in small tubes involve obstruction to the 
passage of air to and from the air vesicles; hence the 
vast difference as regards the symptoms, the suffering 



BRONCHITIS IN BRONCHIAL TUBES 197 

and the danger. The affection is bilateral, a fact 
greatly enhancing the gravity of the affection. An 
incidental physical condition is solidification, generally 
in disseminated portions of lung, the latter varying in 
number and size. These portions of solidified lung 
denote either collapse of pulmonary lobules or lobular 
pneumonia, or both in conjunction. To this incidental 
affection German writers apply the name "catarrhal 
pneumonia." Of course any discussion of pathological 
questions suggested by these names would be here 
out of place. With reference to diagnosis it is to be 
borne in mind that the solidified portions of lung in 
cases of bronchitis seated in small tubes are especially 
situated in the lower lobes. Another incidental physical 
condition is temporary dilatation of the air cells, or 
vesicular emphysema, seated in the upper lobes. Both 
of these incidental conditions are bilateral, like the 
bronchitis with which they are connected. Collapse 
of pulmonary lobules, or lobular pneumonia, or both, 
and emphysema occur in only a certain proportion of 
the cases of bronchitis seated in small tubes. The 
signs, therefore, admit of a division into those which 
relate (1) to the bronchitis, and (2) to these incidental 
affections. With reference to the diagnosis, the fact 
is to be borne in mind that bronchitis seated in small 
tubes occurs chiefly in children and the aged. 

Inspection even in severe cases reveals only moderate 
cyanosis and increase of respiration, in contrast to 
the dyspnea and cyanosis of pneumonia or asthma. 

The physical diagnosis of bronchitis seated in 



198 DISEASES OF THE RESPIRATORY ORGANS 

small tubes rests on negative points, together with 
a positive sign which is uniformly present. This 
sign is the fine, moist hronchial or the so-called suh- 
crepitant rale present on both sides and diffused 
over the chest. The bubbling sounds are to be dis- 
tinguished from the fine, dry crackling sounds or the 
crepitant rale, to the characters of which the former 
in som'e measure approximate. 

The bronchitis gives rise to no dulness on percussion, 
nor to any notable change in weal resonance or fremitus. 
The respiratory murmur, if not obscured by rales, is 
weakened on both sides. Irrespective of being drowned 
by rales, it may be suppressed by the amount of 
bronchial obstruction. These are the negative points 
in the diagnosis. In pulmonary edema fine, moist 
bronchial rales are present on both sides, but in this 
affection there is notable dulness on percussion, and 
the affection occurs in certain pathological connections 
— namely, with mitral stenosis, and disease of the 
kidneys. Acute tubercidosis may present the moist 
bronchial rales with the negative points which, in 
connection with symptoms, characterize bronchitis 
seated in the small tubes. The differentiation is to 
be based on differences pertaining to the history and 
duration, together with the age of the patient. 

The coexistence of the incidental affections, namely, 
collapse of pulmonary lobules, or lobular pneumonia, 
and vicarious emphysema, occasions additional signs. 
Respiration is quickened, expiration being frequently " 
cut short by the pain of an accompanying pleurisy, 



BRONCHITIS IN BRONCHIAL TUBES 199 

so that the patient is seen to flinch with each breath. 
The ah nasi often dilate with each inspiration, and 
cyanosis is common. If the solidified portions of lung 
be considerable in either number or size, there will be 
dulness on percussion in circumscribed situations on 
the posterior aspect of the chest. This will be found on 
both sides, but perhaps more marked on one side. 
Bronchovesicular or the bronchial respiration may be 
present, together with the vocal signs of solidification, 
namely, either increased vocal resonance, or broncho- 
phony and increased vocal fremitus. The moist 
rales produced within solidified portions of lung are 
high in pitch, whereas, if solidification do not exist, 
these rales are comparatively low in pitch. The 
existence of solidification at any point may be deter- 
mined by the pitch of the rales, as well as by the 
foregoing respiratory and vocal signs. 

When there are emphysematous lobules on the 
anterior aspect of the chest in the upper and middle 
regions, on both sides, the resonance on percussion 
is vesiculotympanitic, the respiratory murmur weak- 
ened or suppressed, and the rhythm altered — in short, 
the combination of signs which will be stated under 
the head of emphysema. 

In the cases in which the bronchitis occasions great 
obstruction in the small tubes, and, still more, if 
collapse of lobules, or lobular pneumonia and vicari- 
ous emphysema occur, important signs are obtained 
by inspection. The anterior portion of the chest 
remains expanded, and retraction of the low^r part 
of the chest takes place in the acts of inspiration. 



200 DISEASES OF THE RESPIRATORY ORGANS 

ASTHMA. 

The pathologicophysical condition in a paroxysm 
of asthma, is obstruction in the small bronchial tubes, 
attributable to spasm of the bronchial muscular fibers. 
With this condition is associated a temporary vesic- 
ular emphysema which exists often as a persistent 
affection in persons who are subject to asthma. If 
the emphysematous condition already exists, it is 
increased during the paroxysm of asthma. Bronchitis 
generally coexists, either as a transient or a chronic 
affection. In an asthmatic paroxysm, therefore, 
there are present the signs which are proper to asthma, 
together with those of emphysema, and the associated 
bronchitis may also occasion additional signs. 

On inspection the tremendous inspiratory efforts 
of the patient are pitiful; the accessory muscles of 
inspiration are all in action; and yet, in contrast to 
the dyspnea of tracheal or glottis obstruction, the 
act of inspiration is very quickly accomplished, and 
little drawing-in of the intercostal spaces is visible. 
Closer observation reveals that expiration is slow and 
incomplete, so that in spite of the extreme inspiratory 
efforts the actual amount of air drawn in with each 
breath is much decreased and the patient is cyanosed. 
As a result of these superimposed inspirations, with 
incomplete expiration, the thorax is overinflated and 
assumes the form to be described under Emphysema. 

The physical diagnosis of asthma, like that of 
bronchitis seated in small tubes, is based on nega- 



ASTHMA 201 

tive points taken in connection with a sign which is 
invariably present, namely, dry bronchial rales. These 
rales are more or less intense, and they are diffused 
ovej* the entire chest. They are generally heard at 
a distance. The sibilant and sonorous varieties are 
mingled, and they are constantly changing as regards 
the character of the sounds. 

The negative points are the same as in capillary 
bronchitis, namely, absence of dulness on percussion, 
vocal resonance and fremitus also being unaltered. 
Asthma and bronchitis seated in small tubes agree 
in the fact that obstruction is the important physical 
condition. A highly important differential point 
relates to the frequency of the respirations in cases 
exhibiting an equal degree of dyspnea and cyanosis; 
the respirations are much increased in frequency in 
capillary bronchitis and not in asthma. Patho- 
logically they differ essentially in the fact that the 
obstruction is due in the latter affection to bronchial 
inflammation, and in the former to spasm. The two 
affections differ in the signs representing these different 
conditions — fine, moist bronchial rales existing in one, 
and loud, diffused, dry bronchial rales existing in the 
other. 

Taking the difference, as regards the positive physical 
signs, in connection with the history and symptoms, 
the differentiation of the two affections may be made 
without difficulty. 

The signs which relate to the associated emphy- 
sematous conditions are distinct from those occasioned 



202 DISEASES OF THE RESPIRATORY ORGANS 

by the asthma itself. They will be considered later. 
Coexisting bronchitis may give rise to moist bronchial 
rales more or less coarse. These are, however, often 
wanting, and they are rarely marked during paroxysms 
of asthma. When present in this pathological connec- 
tion they are low in pitch, denoting the absence of 
solidification of lung. 

PULMONARY OR VESICULAR EMPHYSEMA. 

This affection, as a rule, is often more marked 
in the upper lobes. When it is lobar, in contradis- 
tinction from the emphysema existing in comparatively 
a few disseminated or isolated portions of lung, increase 
in volume of the affected lobes is an important physical 
condition standing in relation to certain signs. Dimin- 
ished range of expansion with acts of inspiration is 
another physical condition; the affected lobes are in a 
permanent state of expansion approximating to that 
at the end of the inspiratory act. It follows from these 
conditions that the amount of air is in excess of the 
normal proportion to the solids and liquids in the 
affected lobes. Both lungs are affected, that is, the 
affection is bilateral. In the great majority of cases 
chronic bronchitis coexists, and patients affected with 
emphysema are often, but by no means invariably, 
subject to paroxysms of asthma. Not infrequently 
an asthmatic element, with or without pronounced 
paroxysms of asthma, exists much of the time in 
connection with emphysema. The emphysematous 



PULMONARY OR VESICULAR EMPHYSEMA 203 

condition, as a rule, with few exceptions, is greater 
in the upper lobe of the left, than of the right lung. 

A condition which is generally included under the 
name senile emphysema differs materially from the 
ordinary form of this affection. This condition is 
that also known as senile atrophy of the lungs. The 
volume of the lungs is not increased in this variety 
of emphysema; the proportion of air over the solids 
is, however, in excess, owing to the diminution of the 
latter from atrophy. 

Inspection is of great value in emphysema of the 
"large lung'' type. The thorax is seen to have per- 
manently taken on the form assumed by a normal 
thorax in full inspiration. The ribs are abnormally 
horizontal; the anterior posterior diameter is unusually 
great, often equaling the width of the chest; the 
infracostal angle equals, or is usually greater than, 
a right angle; the normal curvature of the thoracic 
vertebrae is increased. The normal cardiac apex beat 
is not seen; while as a result of a flattened diaphragm 
and the elevation of the sternum, pulsation near the ensi- 
form cartilage is unusually prominent. The external 
jugular veins are abnormally full because the normal 
negative intrathoracic pressure is decreased. Cyanosis 
is usually present, and occasionally of most extreme 
grades. The movements of the chest in inspiration 
are characteristic. In tranquil breathing there is but 
little movement of the upper and anterior regions, 
but in forced breathing the sternum and ribs move 
together as if they were one solid piece. The lower 



204 DISEASES OF THE RESPIRATORY ORGANS 

portion of the chest and the epigastrium are retracted 
in inspiration, or the retraction may be only apparent; 
the costal angle is diminished, the ribs and cartilages 
connected with the sternum being sometimes on a line; 
the soft parts above the clavicle and sternum are often 
notably depressed with inspiration. 

The diagnostic evidence obtained by percussion is 
quite distinctive of lobar emphysema. The reso- 
nance over the upper and middle regions of the chest 
on both sides is vesiculotympanitic, that is, the 
intensity of the resonance is abnormally increased, the 
quality is a combination of the vesicular and tym- 
panitic, and the pitch is more or less raised. Owing 
to the fact that the emphysema is greater on the left 
than on the right side, the vesiculotympanitic reso- 
nance is more marked on the left side. The difference 
in intensity between the two sides may lead to the 
error of regarding the resonance on the right side as 
dulness. The error is avoided by attention to the 
pitch, and the quality of the resonance. If dulness 
existed on the right side, the pitch of the sound should 
be higher on that side; on the other hand, if the differ- 
ence in intensity be due to the greater amount of 
emphysema on the left side, the pitch is higher on 
that side, and the quality vesiculotympanitic. The 
attention of the student is particularly called to the fore- 
going points of distinction. Assuming that a vesiculo- 
tympanitic resonance exists anteriorly on both sides, 
and that it is marked on the left as contrasted with 
the right side, how is the existence of this sign 



PULMONARY OR VESICULAR EMPHYSEMA 205 

on the right side to be determined? The answer is, 
the resonance over the upper is to be compared with 
that over the lower lobe of the right lung. Percussing 
first over the upper lobe of the right lung, and second 
over the lower lobe of this lung, that is, posteriorly, 
below the scapula, or in the infra-axillary region, the 
vesiculotympanitic resonance over the upper lobe is 
rendered manifest. In a series of patients affected 
with emphysema the uniformity of the results of 
percussion is very striking; anteriorly, over the left 
side, the resonance is vesiculotympanitic as com- 
pared with the resonance on the right side, and the 
resonance is shown to be visiculotympanitic on the 
right side anteriorly, as compared with the resonance 
posteriorly below the scapula. 

Beside these distinctive qualitative changes in the 
note, percussion also reveals an increased area of pul- 
monary resonance. The borders of the lungs extend 
lower into the costophrenic sinus, and the anterior 
margins often completely obliterate the area of cardiac 
flatness. 

As regards the abnormal modifications of the 
respiratory murmur in emphysema, there is (1) either 
weakened respiratory murmur without notable change 
in pitch or quality, or suppression of the murmur. 
Diminished intensity of the murmur exists over the 
upper lobes on both sides, as compared with the mur- 
mur over the lower lobes ; and in most cases the greater 
diminution or the suppression is on the left rather 
than on the right side. Exceptions to the latter state- 



206 DISEASES OF THE RESPIRATORY ORGANS 

ment may be caused by obstruction of the bronchial 
tubes on the right, and not on the left side, by an 
accumulation of mucus, and, in rare instances, by the 
fact that the emphysema is greater on the right side. 
Occasionally there is almost suppression below, with 
preserved respiration above, of the emphysematous 
type, and this so continuous as not to be explained by 
obstruction of tubes. (2) Modifications in rhythm 
are not infrequent. These consist in a shortened 
(deferred) inspiratory, and a prolonged expiratory 
sound. In some instances an inspiratory sound is 
wanting, and an expiratory sound is alone heard. The 
prolonged expiratory sound in emphysema is always 
low in pitch and non-tubular in quality, in these 
respects differing from the prolonged expiration which 
denotes solidification of lung, the latter being high 
in pitch and tubular in quality. 

The foregoing signs obtained by percussion and 
auscultation are those which are, in a positive sense, 
diagnostic of emphysema. Associated with these are 
certain important negative points, as follows: vocal 
resonance, vocal fremitus, and whisper are not notably 
altered. These negative points suffice to exclude other 
affections than emphysema. 

In the variety of emphysema distinguished as 
senile, or senile atrophy of the lungs, in which there 
is coalescence of air vesicles from destruction of the 
cell walls without increased volume of the affected 
lobes, the diagnosis is to be based on the vesiculo- 
typanitic resonance on percussion, weakened respi- 



PLE URIS Y—EMP YEMA—H YDRO THORA X 207 

ratory murmur, with, perhaps, the alterations in 
rhythm, sinking of the soft parts above the clavicles, 
and the negative points, exclusive of deformity of the 
chest, which have been described. 

Emphysema can hardly be confounded with any 
other affection than phthisis. The differentiation 
between these two affections is sufficiently easy if 
the diagnostic points, positive and negative, of the 
former, be appreciated. Phthisis occurring in a 
patient affected with emphysema makes a somewhat 
difficult problem in diagnosis; but, by strict attention 
to the associated history and symptoms, together with 
thorough examination of the sputum, errors will 
usually be avoided. Association of emphysema and 
pulmonary tuberculosis is not as uncommon as was 
formerly thought. 

Owing to the frequency with which an asthmatic 
element enters into the clinical history of emphysema, 
the dry bronchial (sibilant and sonorous) rales are 
often present, even when paroxysms of asthma do 
not occur. 

PLEURISY, ACUTE AND CHRONIC— EMPYEMA— 
HYDROTHORAX. 

In the first stage of acute pleurisy — that is, prior 
to the effusion of liquid — the physical conditions 
are the presence of more or less recently exuded, 
soft fibrin upon the pleural surfaces, which are still 
in contact, and restrained movements of, respiration 



208 DISEASES OF THE RESPIRATORY ORGANS 

on the affected side in consequence of the pain which 
they occasion. In the second stage serous liquid 
accumulates within the pleural cavity, the quantity 
varying in different cases, sometimes, although rarely, 
filling the chest on the affected side. In proportion 
to the quantity of liquid, the space over which the 
pleural surfaces are in contact is restricted, the move- 
ments of these surfaces over each other are limited, 
and the lung is condensed. In the third stage the 
liquid decreases, the space over which the pleural 
surfaces are in contact increases, and the compressed 
lung is more or less expanded. The fibrin upon the 
pleural surfaces becomes more dense and adherent. 
The surfaces may become agglutinated by the inter- 
vening fibrin. Finally, in convalescence, permanent 
adhesions may result from the production or growth of 
areolar tissue. 

In subacute and chronic pleurisy there is the same 
series of physical conditions, the points of difference 
being, as a rule, a less amount of exudation, and a 
greater amount of effused liquid. The quantity of 
liquid in chronic pleurisy is often sufficient to compress 
the lung into a small solid mass situated at the upper 
and posterior part of the chest and to dilate the 
affected side. The heart is often removed from its 
normal situation. If the pleurisy be on the left side, 
the heart may be pushed laterally beyond the right 
margin of the sternum; if the pleurisy be on the right 
side, the heart is pushed laterally to the left of its 
normal situation. 



PLEURISY— EMPYEMA—HYDROTHORAX 209 

In empyema the accumulation of pus is apt to be 
still greater than that of serous effusion in simple 
chronic pleurisy, causing, of course, greater dilatation 
of the chest, and more displacement of the heart. 

In these varieties of pleurisy the affection, with 
rare exceptions, is unilateral. 

In hydrotJiorax the conditions differ, (1) as regards 
the absence of the exudation of fibrin; (2) the affec- 
tion is usually bilateral, the effusion of liquid taking 
place in both pleural cavities; and, (3) although the 
quantity of liquid may be considerably greater on 
one side, and this is almost invariably the right side, 
the accumulation very rarely, if ever, is sufficient to 
cause much dilatation of the chest on that side, with 
complete condensation of the lung, and notable dis- 
placement of the heart. 

The signs in acute fibrinous pleurisy are relative 
feebleness of the respiratory murmur on the affected 
side, from the restrained respiratory movements on 
that side, and a rubbing friction sound. The friction 
sound cannot be heard if only the diaphragmatic or 
mediastinal pleura is inflamed. The former sign is 
not distinctive of pleurisy, being present when the 
respiratory movements on one side are restrained by 
pain in intercostal neuralgia and pleurodynia. A 
friction sound is not always obtained. In the absence 
of this sound the physical diagnosis of acute pleurisy 
cannot be made with positiveness prior to the effusion 
of liquid. 

When in doubt as to the site of origin of rales which 
14 



210 DISEASES OF THE RESPIRATORY ORGANS 

may be friction sounds or pulmonary crepitations, if 
the patient cough, the character of pulmonary rales is 
usually altered, and they may even disappear, while 
pleuritic friction sounds are unaffected. Also pressure 
of the stethoscope or hand may intensify the friction 
rub but does not alter the pulmonary crepitation. 
The friction sound is usually, but not invariably, 
heard only in inspiration. 

Assuming that the general and local symptoms point 
to an acute inflammatory affection, the differential 
diagnosis relates to pleurisy and pneumonia. A fric- 
tion sound is usually present in the latter because the 
adjacent pleura is almost invariably inflamed. The 
common sign of pneumonia, the crepitant rale, being 
wanting, the differentiation, in this stage, must rest on 
diagnostic points pertaining to changes in resonance 
and breath sounds. The crepitant rale may occur at 
the inception of pleurisy, without coexisting pneumonia, 
the mechanism of production being the same as in 
pneumonia. 

In the second stage of acute pleurisy the diag- 
nostic signs are those which denote the presence of 
liquid within the pleural cavity. These signs are 
simple and distinctive. The affected side is larger, 
and the intercostal depressions less distinct than 
normally; it moves less freely with respiration. There 
is either dulness or flatness on percussion at the base 
of the chest, extending upward a distance propor- 
tionate to the quantity of liquid. If the trunk be in 
a vertical position — that is, the patient sitting or 



PLEURISY— EMPYEMA— HYDROTHORAX 211 

standing — the line of demarcation between the dulness 
or flatness and pulmonary resonance is curved. Pos- 
teriorly, the line of dulness or flatness is found to be 
a curve, starting about 2 inches from the posterior 
median line, and reaching its highest point at the 
posterior axillary line, the curve then descending in 
the axilla, to reach the liver or cardiac dulness in 
front, according to the side and the amount of the 
effusion (Ellis's, or Garland's line). In patients who 
have been confined to bed, the highest point of the line 
of dulness is frequently in a line drawn vertically 
through the middle of the scapula. 

Having ascertained the line forming the upper 
boundary of dulness or flatness on the anterior aspect 
of the chest (the patient sitting or standing), if the 
position be changed to recumbency on the back, 
and the pulmonary resonance be found then to extend 
more or less below this line, this fact is demonstrative 
proof of the presence of liquid. The amount of 
shifting of' this line of dulness may be only 1 or 2 
inches in normal or rather flat chests, while in deep 
barrel-shaped chests 3 or 4 inches of movement may 
be found. 

Where there is free pleuritic exudate on one side, 
there is found with considerable uniformity a trian- 
gular area of dulness on the opposite or unaffected 
side. The base of this area is made by the line of the 
base of the lung, and extends 2 or 3 inches from the 
posterior median line; the vertical side is somewhat 
longer usually and is as high in the midline as the 



212 DISEASES OF THE RESPIRATORY ORGANS 

upper level of the fluid on the affected side. This 
is known as fJie paravertebral triangle of dulness. 
Proof in this way is obtained in a large majority of 
cases, the exceptional cases being those in which the 
pleural surfaces are united, either by agglutination or 
permanent adhesions, above the level of the liquid. 
An additional means of determining the level of the 
fluid, especially at the right base posteriorly where the 
presence of the liver may cause confusion on percussion, 
is by tapping one coin held firmly against the upper 
chest in front with another coin, when the ear below 
the level of the fluid will detect a much better trans- 
mission of the sound thus produced than when the 
ear is above the level of the fluid. Flatness over fluid 
is usually more intense and the sense of resistance to 
the pleximeter finger greater than over consolidatd 
lung. 

The resonance on percussion over the lung above 
the level of the liquid is generally vesiculotympanitic 
(Skodaic resonance) — the intensity increased, the pitch 
raised, the vesicular and the tympanitic quality 
combined. Sometimes there is so little vesicular 
quality in this vesiculotympanitic resonance that it 
may seem to be purely tympanitic, and is suggestive 
of pneumothorax. Associated signs will always pre- 
vent this error of observation. 

As a rule vocal resonance and fremitus are either 
notabty lessened or suppressed over the portion of 
the chest situated below the level of the liquid. 
There are occasional exceptions to this rule. 



PLEURISY— EMPYEMA— HYDROTHORAX 213 

The respiratory sound below the level of the liquid 
is suppressed. If any be heard, it is transmitted 
either from the lung above the liquid, or laterally, 
from the lung on the other side of the chest. Above 
the liquid the respiratory sound, as a rule, is weak- 
ened. If the amount of liquid be sufficient to produce 
much condensation of lung, the respiratory sound is 
bronchovesicular. Sometimes, owing to the pleural 
surfaces above being adherent, a strip of lung at 
the level of the liquid is sufficiently condensed by 
compression to give a bronchial respiration. Under 
these circumstances there will be either broncho- 
phony or the modification of that sign known as 
egophony. If the lung be not sufficiently compressed 
for the production of these signs of solidification, the 
vocal resonance is simply more or less increased. 
The fremitus is usually increased above the liquid. 
Over the unaffected side the respiratory murmur is 
increased in intensity — compensatory respiration. 

The foregoing signs are present when the pleural 
cavity is partially filled; a quarter, a half, or two- 
thirds of the thoracic space being occupied by liquid. 
The signs present when the cavity is completely filled 
will be presently stated in connection with chronic 
pleurisy. 

The signs which have been stated show not only 
the presence of liquid but its quantity. By means 
of, these signs are readily ascertained the progressive 
increase or decrease in the quantity of liquid, and 
its disappearance. After the liquid has disappeared 



214 DISEASES OF THE RESPIRATORY ORGANS 

often notable dulness on percussion remains for some 
time, showing the presence of fibrin not yet absorbed. 
During the decrease of the hquid, and after its dis- 
appearance, a friction murmur is often perceived. 
This murmur is now apt to be rough — a rasping, 
grating, or creaking sound. It may be loud enough to 
be heard by the patient and by others at a distance 
from the chest. It continues sometimes for a con- 
siderable period. 

The physical diagnosis in cases of chronic pleurisy, 
when the liquid occupies a portion only of the thoracic 
space, rests, of course, on precisely the same signs as 
in cases of acute pleurisy. Concident pleural thick- 
ening may, however, limit the respiratory movement 
of the affected side much more than in the case of 
acute pleural effusion, while occasionally that side is 
distinctly contracted. If, however, the chest on the 
affected side be filled and dilated, certain of the signs 
which have been stated are wanting, and others are 
added. The affected side is everywhere flat on per- 
cussion. Flatness on percussion over the whole of 
one side, the affection being chronic, denotes, as a 
rule, with rare exceptions, either chronic simple 
pleurisy or empyema. Respiratory sound is wanting 
except at the summit over or near the compressed 
lung, where it is bronchial. Some cases offer an 
important exception to this rule, namely, the bronchial 
respiration is diffused over the greater part, or even 
the whole, of the affected side. The student should 
bear in mind this fact, otherwise the diffusion of the 



PLEURISY— EMPYEMA— HYDROTHORAX 215 

bronchial respiration may lead to the suspicion that 
the flatness on " percussion denotes solidification of 
lung and not the presence of liquid. Other signs, 
however, should always correct this error. Vocal 
resonance and fremitus are, with some exceptions, 
either suppressed or notably diminished over the 
whole of the affected side. Generally, even when 
the chest is not dilated, the intercostal depressions 
are lessened or abolished. If the walls of the chest 
be thinly covered with integument, the two sides 
present a marked contrast in this respect. This is 
seen especially at the middle and lower regions of 
the chest anteriorly and laterally. It is especially 
marked at the end of the inspiratory act. If the 
affected side be dilated, this is apparent on inspection, 
and may be determined accurately by measurement. 
The respiratory movements on the affected side are 
diminished or annulled, and they are increased on 
the healthy side, the two sides affording a marked 
contrast in this regard. If the pleurisy be on the left 
side, the impulses of the heart are not infrequently 
felt on the right of the sternum. If the impulses 
cannot be felt, auscultation shows the maximum of 
the intensity of the heart sounds to be more or less 
removed to the right. If the pleurisy be on the right 
side, the impulses or sounds of the heart denote more 
or less displacement laterally to the left, and this 
altered position may be still further determined by 
percussion of the cardiac border adjacent to healthy 
lung. The intensity of the respiratory murmur on 



216 DISEASES OF THE RESPIRATORY ORGANS 

the unaffected side is notably increased, as the patient 
is forced to do practically all his breathing with one 
lung. 

In cases of empyema the same signs are present 
as in simple pleural effusion. Neglected cases come 
under observation with large accumulations of pus 
which give signs like those found in large non-purulent 
effusions. The character of the liquid does not alter 
appreciably any of the signs which haVe been stated. 
Dilatation of the affected side of the chest is more 
apt to occur, and to be more marked than in simple 
pleurisy. The differential diagnosis between these two 
varieties of pleurisy is to be made with positiveness 
by the introduction of the needle of an exploratory 
syringe having good suction force, previously cleaned 
and carbolized, and obtaining enough of the liquid 
to ascertain its character. 

When the left pleural cavity is filled with pus, the 
movements of the heart sometimes give to the affected 
side of the chest an impulse perceived by the eye and 
touch; hence the term, pulsating empyema. This con- 
dition has been observed even when the empyema 
has been confined to the right pleural cavity. After 
a spontaneous perforation of the chest, followed by a 
circumscribed purulent collection beneath the integu- 
ment, communicating with the pus w^ithin the pleural 
cavity, the tumor thus formed sometimes has a strong 
pulsation which is synchronous with the ventricular 
systole, and may give rise to the suspicion of aneurism. 

Empyema of less advanced grade is much more 



PLE URIS Y—EMP YE MA —H YDRO THORA X 217 

frequently met. Here the signs are usually similar to 
those encountered in small serous effusions — dulness, 
decreased (usually faint bronchial) breath sounds, 
voice and fremitus. On the other hand, there is a 
much greater tendency to the formation of adhesions 
and to encapsulation, so that movable dulness and 
the S-shaped line of Ellis are less frequent, while 
atypical signs suggesting consolidation are occasionally 
met. 

In cases of hydrothorax the signs denote partial 
filling of the chest on both sides. The affection is 
usually bilateral. Generally the quantity of liquid in 
the two sides is not equal, and there is often a notable 
disparity in this respect. Friction sounds are never 
present. Variation of the level of the liquid with 
change of the position of the patient from the verti- 
cal to the horizontal is nearly always determinable. 
Hydrothorax, meaning by this term a purely dropsi- 
cal affection, is to be differentiated from double 
pleurisy with effusion. The history and symptoms, 
taken in connection with the signs, suffice for this 
discrimination. 

Exceptional Physical Signs in Pleurisy.^ — "The vocal 
fremitus may not be lost below the level of the fluid. 

"Above the level of the fluid, over the compressed 
lung, there may be cavernous breathing and gurgling 
rales. 

"A subcrepitant rale may be heard below the level 

^ Delafield: Lectures on the Practice of Medicine, 1903. 



218 DISEASES OF THE RESPIRATORY ORGANS 

of the fluid, the level being demonstrated by the 
aspirator. 

"Sacculated effusions give irregular physical signs 
which vary with the position of the fluid. The effu- 
sions are most easily made out if they are in contact 
with the wall of the chest. 

'^Most of the sacculated pleurisies I have seen have 
been situated about the root of the lung, gave the 
maximum flatness at some point between the scapula 
and the vertebral column, and were best aspirated at 
the point of maximum flatness. In some of these 
cases there was flatness and absence of breathing 
over the fluid; in some, flatness and bronchial voice 
and breathing; in some there was pulmonary reso- 
nance with bronchial voice and breathing over the 
lower part of the chest where there was no fluid. '^ 

PNEUMOTHORAX— HYDROPNEUMOTHORAX— 
PYOPNEUMOTHORAX. 

In the rare cases of pneumothorax, that is, as dis- 
tinguished from hydropneumothorax and pyopneumo- 
thorax, the physical conditions are the presence 
of air partially or completely occupying the thoracic 
space, and condensation of lung in proportion to the 
space occupied by air. 

The diagnostic signs on the affected side are enlarge- 
ment with decreased movability on respiration, and 
obliteration of the normal intercostal depressions, 
absent or displaced cardiac impulse, occasionally 



PNEUMOTHORAX—HYDROPNEUMOTHORAX 219 

distention of the right jugular vein in right-sided 
cases, frequently dyspnea on mild exertion; a purely 
tympanitic resonance over a portion or the whole of 
the affected side of the chest; suppression of the 
vesicular murmur, with notable diminution or sup- 
pression of vocal resonance and fremitus over a space 
in which tympanitic resonance is obtained. Over 
the compressed lung, if the condensation amount to 
complete or considerable solidification, and if adhe- 
sions hold the lung in contact with the chest wall at 
some point, there will be bronchial respiration and 
bronchophony; if the solidification be neither com- 
plete nor considerable, there will be bronchovesicular 
respiration with increased vocal resonance and fremi- 
tus. As a matter of fact, however, the lung w^hen 
compressed is usually shrunken against the medi- 
astinum and not directly accessible to percussion 
or auscultation. The accumulation of air may be 
sufficient to dilate the affected side, and restrain or 
annul the respiratory movements on this side. The 
appearances on inspection are then precisely the 
same as in the cases of chronic pleurisy and empyema, 
in which the affected side is dilated from the presence 
of liquid. Pneumothorax is, however, at once differ- 
entiated by the tj^rupanitic resonance and by the 
abnormal decreased sense of resistance on percussion. 
If one side of the chest be more or less dilated, and 
the resonance over the side be purely tympanitic, 
the thoracic space must be filled, not with liquid, but 
with air. The intensity of the respiratory murmur 



220 DISEASES OF THE RESPIRATORY ORGANS 

on the healthy side is increased. The heart is dis- 
placed toward the unaffected side of the chest. The 
area of cardiac flatness disappears in left-sided pneu- 
mothorax while in right-sided cases liver flatness is 
much decreased and resonance extends down to the 
level of the attachment of the diaphragm. 



Compressed 
lung 




Heart displaced 

Apex beat to the 

right of sternum. 



Tympany 



Succussion on shaking^ 



Flat on percussion with 

loss of vocal resonance and 

loss of vocal fremitus . 



Fig. 13. — Left pyothorax. Metallic tinkling may be produced 
by the fluid dropping from the apex of the chest into fluid below. 
(After Maydl.) 



In the great majority of cases in wJiich the pleural 
cavity contains air there is also present more or less 
liquid which may be serous or purulent. The affec- 
tion is then known as hydropneumothorax if the liquid 



PNEUMOTHORAX— HYDROPNEUMOTHORAX 221 

be serous, and pyopneumothorax if it be purulent. 
The physical conditions are the same as in pneumo- 
thorax, Avith the addition of the presence of liquid. 
The relative proportions of liquid and air in different 
cases are variable, and, also, in the same case at 
different periods. 

The physical diagnosis of hydropneumothorax and 
of pyopneumothorax, as distinguished from pneumo- 
thorax, embraces the signs of liquid, in addition to 
those of air, within the pleural cavity. If the quan- 
tity of liquid be large or considerable, percussion at 
the base of the chest gives flatness, extending upward 
more or less, and tympanitic resonance above, the 
patient either sitting or standing. A change frorn the 
vertical to the horizontal position invariably causes 
variation of the upper limit of the flatness, inasmuch 
as the liquid and air change their relative situations 
without an exception. The level of the liquid follows 
completely the laws of gravity, in contrast to the 
relatively slight shifting dulness and the S-shaped 
Ellis line where fluid alone is present. The quan- 
tity of liquid is determined approximately, by ascer- 
taining the space over which the flatness on percussion 
extends. The line which divides the flatness and the 
tympanitic resonance does not accurately denote the 
level of the liquid, because tympanitic resonance is 
transmitted a certain distance below this level, hence 
it is always to be assumed that the level of the liquid 
is somewhat higher than the upper boundary of the 
flatness. 



222 DISEASES OF THE RESPIRATORY ORGANS 

In either pneumothorax, hj^dropneumothorax, or 
pyopneumothorax a group of special auscultatory signs 
is often found which are highly diagnostic, indeed 
almost pathognomonic. These signs are amphoric 
respiration, amphoric voice or echo, metallic tinkling, 
and the coin sound. The amphoric and the tinkling 
sounds may be present, either without the other, but 
they are not infrequently associated. Both signs are 
absent in some cases and they are not present in the 
same case at all times; their absence, therefore, by no 
means excludes the affections, and they are not essen- 
tial to the diagnosis. When present they denote 
either air, or air and liquid, in the pleural cavity 
with perforation of lung, or a large phthisical cavity. 
Their occurrence in the latter is comparatively rare, 
and whenever they are associated with other signs 
already stated, their diagnostic import is demonstrative. 

The coin sound consists in a distinctive bell-like 
quality given to the sound heard through the affected 
chest when a coin is tapped sharply against another 
held firmly in contact with the chest wall. The sound 
produced, instead of being distant and muffled as 
through a normal lung, is clear, intense, ringing, and 
can be likened to the sound a small pebble makes when 
dropped into a deep well. Absence of coin sound 
does not exclude pneumothorax. 

Hydropneumothorax or pyopneumothorax may 
almost invariably be diagnosed instantly by the 
presence of a succussion sound. Whenever distinct 
splashing is produced by succussion and referable to 



ACUTE LOBAR PNEUMONIA 223 

the chest, that is, not produced within the stomach, 
it is demonstrative of the presence of air and hquid 
within the pleural cavity. 

- ACUTE LOBAR PNEUMONIA. 

In the first stage of this disease there is an abnor- 
mal accumulation of blood within the vessels of the 
affected lobe (active congestion or hyperemia), 
with some exudation within the air vesicles and 
bronchioles. Generally there is some exuded fibrin 
upon the pleural surface, due to circumscribed 
dry pleurisy. In most cases there is also circum- 
scribed bronchitis, which is limited to the tubes within 
the affected lobe. In the second stage there is solidi- 
fication due to the increase of exudation within the 
air vesicles. The solidification, at first limited, 
extends either rapidly or slowly, as a rule, over the 
whole lobe. Exceptionally more or less liquid effu- 
sion into the pleural cavity takes place (pleuropneu- 
monia), the pleurisy then extending beyond the limits 
of the affected lobe. In this stage the pneumonia 
may involve either another lobe of the lung primarily 
affected, or a lobe of the opposite lung, and sometimes 
the disease, by successive invasions, extends over 
the whole of one lung, together with a lobe of the 
opposite lung. The pneumonia, in these secondary 
invasions, is usually accompanied by pleurisy and 
bronchitis. 

In the stage of resolution the solidification of the 



224 DISEASES OF THE RESPIRATORY ORGANS 

affected lobe or lobes decreases, sometimes rapidly 
and sometimes slowly, until the normal condition 
is restored. If resolution does not take place, 
the consolidated area becomes gradually organized 
by ingrowth of fibroblasts. Exceptionally pus is 
collected in a cavity, or in cavities within the lung 
constituting pulmonary abscess, or quite frequentlj^ 
within the pleura producing empyema. 

The physical diagnosis of acute lobar pneumonia 
in the first stage can be frequently made by inspection 
alone. The flushed, frequently slightly cyanotic face, 
the presence of herpes about the mouth, increased 
respu'ation with inspiratory dilatation of the ali nasi, 
and frequent flinching of the patient with each expi- 
ration are signs of great significance. While if the 
inspection of sputum cups be permitted in physical 
diagnosis, the most reliable of all signs of pneumonia, 
and sometimes the earliest sign, may be found — the 
tenacious, slightly reddish or yellowish, sometimes 
prune-juice-colored expectoration. Localization of the 
process at this stage may be suggested by decreased 
respiratory motion on one side but must be based on 
the presence of the crepitant rale, with moderate or 
slight dulness on percussion, and diminished vesicular 
respiratory murmur over the affected lobe. There 
is sometimes in this stage a pleuritic rubbing sound 
over the affected lobe. The crepitant rale is not 
always present, and hence the affection cannot be 
excluded by the absence of this sign. When present, 
taken in connection with the symptoms, this sign is 



ACUTE LOBAR PNEUMONIA 225 

of great diagnostic value. It is important not to 
mistake for this sign fine bubbling, or the subcrepitant 
rale. When the crepitant rale is wanting, a positive 
physical diagnosis must be deferred until more or less 
of the affected lobe becomes solidified, that is, when 
the disease passes into the second stage. 

In certain cases the signs of slight dulness with 
decreased breath sounds are alone present for a con- 
siderable period. Indeed, bronchial breathing may 
never appear. Such cases have been called central 
pneumonias on the supposition that the process was 
at that stage limited to the region of the root of the 
lung, and extended slowly to the surface. Recent 
investigation by the .r-ray has, however, shown that 
they originate at the surface; but, until they have 
extended to the large bronchi at the root, the bronchial 
sounds are not well transmitted.^ 

The physical signs of the "first stage of pneumonia" 
are therefore the signs occurring, not merely in the 
stage of engorgement, but up to the stage when con- 
solidation extends from the surface of the lung to the 
large bronchi at the root. 

The diagnosis in the stage of hepatization is to be based 
on the signs of solidification furnished by ausculta- 
tion and percussion. The auscultatory signs are the 
bronchovesicular, followed by the bronchial respira- 
tion; increased vocal resonance, followed by broncho- 
phony, and increased bronchial whisper, followed by 

^ Mason: Am. Jour. Dis. Child., March, 1916, xi. 
15 



226 DISEASES OF THE RESPIRATORY ORGANS 

whispering bronchophony. The signs of sohdifica- 
tion are manifested at first within a circumscribed 
space, situated over either the upper, the lower, or 
the middle portion of the affected lobe, and either 
rapidly or slowly the signs extend, in most cases 
over the entire lobe. The crepitant rale, if it has 
been present in the first, generally disappears in the 
second stage. Sometimes, however, it is not entirely 
lost in this stage. The bronchovesicular respiration, 
increased vocal resonance, and increased bronchial 
whisper are present when the solidification is slight or 
moderate; the bronchial respiration, bronchophony, 
and bronchophonic whisper take their place when 
the solidification becomes considerable or complete. 
The latter signs, as a rule, speedily follow, inasmuch 
as the solidification in most cases quickly becomes 
complete or considerable. The foregoing three signs, 
denoting considerable or complete solidification, are 
usually present. Bronchial respiration, however, is 
sometimes present without bronchophony, and vice 
versa. Either, present alone, sufiices to show the 
existence and the extent of the solidification. Moist 
bronchial or bubbling rales are sometimes, but rarely, 
heard over the affected lobe. 

There is notable dulness on percussion in the 
second stage. The dulness may approximate and 
even amount to flatness. If a single lobe be affected, 
the dulness or flatness extends over a space corre- 
sponding to that occupied by the lobe or the portion 
of it which is solidified. In the anterolateral aspects 



ACUTE LOBAR PNEUMONIA 227 

of the chest, ' the dividing Hne between the soHdified 
and the healthy lobe is readily ascertained by per- 
cussion. The line thus obtained is not, however, 
identical with the normal interlobar l;ne (vide p. 69), 
for the affected lobe distended with exudate is larger 
than normally. 

Whenever one lobe of a lung is affected, the reso- 
nance over the unaffected part of the same lung is 
abnormally increased, the pitch is raised, and the 
quality is vesiculot;^Tiipanitic. Vesiculotympanitic 
resonance, in other words, is produced, as over pleural 
effusions, because the unaffected lobe is relaxed (vide 
p. 101). This renders more marked the contrast 
between dulness over the solidified, and resonance 
over the healthy, lobe. 

Over a portion of an upper lobe in the second stage, 
instead of notable dulness or flatness, there may be 
marked tympanitic resonance. This resonance pro- 
ceeds from air within the trachea and the bronchi 
exterior to the lungs, the lung substance being com- 
pletely solidified; it is chiefly or especially marked 
over the site of these air tubes (vide Williams' Tracheal 
Tone, p. 105). In some cases the tympanitic resonance 
has either the cracked-metal or the amphoric intona- 
tion. These signs per se might suggest either pneu- 
mothorax or phthisical cavities; the associated respira- 
tory and vocal signs, however, show only solidification 
of lung. In cases of pneumonia aft'ecting the left lung, 
a tympanitic resonance is not infrequently propagated 
from the stomach more or less upward over the aft'ected 



228 DISEASES OF THE RESPIRATORY ORGANS 

side of the chest. This may be readily traced to the 
stomach. On the right side a tympanitic resonance 
is sometimes propagated a certain distance upward 
from the transverse colon. 

The commencement of the stage of resolution is 
denoted by a bronchovesicular respiration. The first 
change observed is the presence of a little vesicular 
quality in the inspiratory sound. When this is 
observed, the respiration is no longer bronchial, but 
has become bronchovesicular, although the pitch is 
still high, and the expiration is prolonged, high, tubu- 
lar. This slight change shows that air begins to 
enter the pulmonary vesicles. As resolution goes on, 
more and more of the vesicular takes the place of the 
tubular quality in the inspiratory sound, and the 
pitch is lowered in proportion; the expiratory sound 
becomes proportionately less and less prolonged, its 
pitch lowered, its quality less tubular, until, at length, 
the normal characters of the respiratory murmur are 
regained. Resolution is then complete. 

While the bronchovesicular respiration is under- 
going the modifications just stated, the vocal sounds 
have corresponding changes. Bronchophony persists 
for some time after the respiration has become bron- 
chovesicular, and then disappears, increased vocal 
resonance generally taking its place and persisting 
until resolution is completed. The bronchial whisper 
loses its bronchophonic characters, and is simply 
increased until its normal characters are regained. 
While the solidification is complete, the vocal fremi- 



ACUTE LOBAR PNEUMONIA 229 

tus may, or may not, be increased. It is sometimes 
diminished. When, however, resolution has so far 
progressed that bronchophony is lost, the fremitus is 
usually greater than in health, and so continues, but 
progressively lessening until the solidification entirely 
disappears. ^ 

During the progress of resolution, the dulness on 
percussion diminishes in proportion as air enters the 
air vesicles. If tympanitic resonance have been 
present over the upper lobe, this gives place to a 
vesicular resonance. Some dulness, however, remains 
after the completion of resolution, and persists until 
the exuded fibrin on the pleural surface is absorbed. 
The amount of dulness remaining when the respi- 
ratory fand vocal signs denote resolution, is propor- 
tionate ,to the quantity of exudation incident to the 
associated pleurisy. 

In this stage the crepitant rale not infrequently 
returns, if it has entirely disappeared during the 
second stage, and if it has persisted, it is more 
marked and diffused. It is now known as the return- 
ing crepitant rale. More frequently the rale in this 
stage is a fine bubbling or the so-called subcrepitant. 
Both rales are not infrequently associated, and, from 
the distinctive characters of each, they are readily dis- 
tinguished. Moist rales, more or less fine or coarse, 
are not infrequent. The pitch of these rales remains 
more or less high until the solidifying exudation is 
completely absorbed. 

If the affection pass into the stage of delayed reso- 



230 DISEASES OF THE RESPIRATORY ORGANS 

lution the respiratory sounds are more or less of the 
bronchial characters. Bubbling bronchial rales, coarse 
and fine, are abundant. Weak bronchophony may 
persist, or the vocal resonance may be diminished. 
Fremitus may, or may not, be increased. Notable 
dulness or flatness on percussion remains. The 
majority of cases spoken of clinically as delayed 
resolution are in reality small encapsulated empyemas, 
while occasional cases turn out to be acute pneumonic 
phthisis. 

If the pneumonia result in pulmonic abscess, there 
will be notable dulness or flatness on percussion 
within a circumscribed space, together with absence 
of respiratory murmur, and diminished or suppressed 
vocal resonance. These signs warrant a probable 
diagnosis which is corroborated by the sudden expecto- 
ration of pus in a considerable quantity. The signs 
just stated may then be followed by those denoting a 
cavity — namely, cavernous respiration and whisper, 
with intense vocal resonance. 



CIRCUMSCRIBED PNEUMONIA— EMBOLIC PNEU- 
MONIA— HEMORRHAGIC INFARCTUS OR PUL- 
MONARY APOPLEXY. 

The form of pneumonia known as lobular pneu- 
monia, occurring in children, has been considered 
{vide Bronchitis Seated in Small-sized Tubes). When- 
ever circumscribed, as a rule, pneumonia is secondary 



CIRCUMSCRIBED AND EMBOLIC PNEUMONIA 231 

to some other pulmonary affection. Circumscribed 
pneumonia, giving rise to an intravesicular exudation, 
which may disappear readily by resolution or absorp- 
tion, is not very infrequent in cases of phthisis. The 
signs are those which represent solidification of lung 
within an area more or less circumscribed; but the 
differentiation, from the solidification due to phthisis, 
can only be positively made, after the signs have 
shown that the solidification has notably diminished, 
or disappeared. 

In embolic pneumonia there may be dulness on 
percussion, with feeble bronchial or bronchovesicular 
respiration, or suppression of respiratory sound, weak 
bronchophony or increase of vocal resonance, within a 
circumscribed space, or spaces, generally on the posterior 
aspect of the chest, and oftenest on the right side. These 
signs, taken in connection with symptoms and patho- 
logical conditions consistent with the supposition of em- 
boli received into the right side of the heart, namely, 
when the pulmonary symptoms follow puerperal disease, 
ulcers, wounds, injuries, or venous thrombosis, render 
the diagnosis quite positive. If, however, the pulmo- 
nary affection consists of small disseminated nodules, the 
foregoing signs will not be present. The diagnosis 
then must be based on the history and symptoms, 
taken in connection with the exclusion of other pul- 
monary affections by the absence of signs, which 
should be present if they existed. Bubbling rales, the 
pitch more or less raised, at different situations may 
indicate the probable sites of the nodules. There may 



232 DISEASES OF THE RESPIRATORY ORGANS 

be pleuritic friction sounds. The signs may show, as 
a comphcation, pleurisy with effusion. 

Extravasation of blood (pneumorrhagia), if it be in 
small spaces, give rise to no definite physical signs. 
If, however, extravasation extend over a considerable 
space, there will be dulness on percussion, with feeble 
or suppressed respiratory sound within an area corre- 
sponding to the extent of the extravasation. Within, 
and near this area, there will be likely to be moist 
bronchial rales more or less fine or coarse. 

PULMONARY GANGRENE. 

In diffused pulmonary gangrene the physical signs 
are those of solidification extending over the greater 
part or the whole of a lobe. The diagnosis, however, 
can only be made when, in connection with these 
signs, there are present the characteristic fetor of the 
breath and expectoration. ' 

In circumscribed gangrene there is dulness or flat- 
ness on percussion within an area corresponding to 
the extent of the affection, with either suppression 
of respiratory sound or bronchial respiration, and 
the vocal signs of solidification. Within and near 
this space moist bronchial rales, more or less raised 
in pitch, are likely to be heard. The . situation is 
usually on the posterior aspect of the chest. These 
signs do not suffice for a positive diagnosis without 
the characteristic breath and expectoration. Caver- 
nous signs may appear after the gangrenous portion 
of lung has sloughed away and been expectorated. 



PULMONARY EDEMA 233 

PULMONARY EDEMA. 

The physical condition expressed by the term pul- 
monary edema is the presence of effused serum within 
the air vesicles. With this condition is associated 
more or less pulmonary congestion. 

In cases of pulmonary edema developed rapidly 
and largely in connection with renal disease, with 
obstruction at the mitral orifice of the heart, or with 
both these affections combined, giving rise to great 
dyspnea, and liable to end speedily in death, the 
following are the diagnostic signs: Dyspnea, with in- 
creasing cyanosis; dulness on percussion on both sides 
of the chest, especially over the lower lobes, fine 
bubbling or so-called subcrepitant rales diffused over 
the chest on both sides, together with coarser bubbling 
sounds, and the murmur of respiration notably weak or 
suppressed over the lower lobes. Inasmuch as the 
lungs are not solidified the rales are low in pitch. 
The vocal signs of solidification are, of course, wanting. 
Occasionally the crepitant rale is mingled with the 
fine bubbling sounds. 

This form of the affection is to be differentiated 
from hydrothorax with large effusion, and from so- 
called capillary bronchitis. Hydrothorax is always 
associated with more or less anasarca, or general 
dropsy, whereas, pulmonary edema, even when 
dependent on renal disease, may occur without 
dropsical effusion elsewhere. Moreover, the presence 
of liquid within the pleural cavities, and its amount, 



234 DISEASES OF THE RESPIRATORY ORGANS 

may always be determined demonstratively in eases 
of hydrothorax {mde Pleurisy with Effusion and 
Hydrothorax) . Capillary bronchitis occurs chiefly in 
children. The so-called subcrepitant rale on both 
sides of the chest is the diagnostic sign of this affec- 
tion, but it is not accompanied by dulness on percus- 
sion, except in so far as the bronchitis may be 
associated with lobular pneumonia or collapse of 
pulmonary lobules. The rapid development of the 
edema and its pathological connections are diagnostic 
points to be taken into account. 

Pneumonia is excluded by the fact that the affec- 
tion is at the beginning bilateral, and by the absence 
of the signs of solidification of lung. 

Pulmonary edema less in degree and diffusion, 
has, of course, the same signs, not as marked and 
not as extensive — namely, dulness on percussion and 
fine bubbling sounds or the so-called subcrepitant 
rales. In this form the affection is bilateral, and 
seated especially in the posterior and inferior por- 
tions of the lungs. Moreover, this form has the 
same pathological connections, namely, with disease 
of the kidneys, and mitral lesions of the heart. The 
low pitch of the bronchial rales, and the absence 
of the respiratory and vocal signs of solidification, 
together with the fact of the affection being bilateral, 
and the coexistence of disease of the heart or kidneys, 
constitute the basis of a positive diagnosis. 

Hypostatic congestion of the lungs may occasion 
a certain amount of pulmonary edema. The physi- 



NEOPLASMS OF LUNG—TUMORS IN CHEST 235 

cal diagnosis is to be based on bilateral dulness on 
the posterior aspect of the chest, with low-pitched, 
fine bubbling sounds, or the so-called subcrepitant 
rales on both sides, these signs occurring under cir- 
cumstances which lead to the supposition of this 
form of congestion. 

NEOPLASMS OF LUNG— TUMORS WITHIN THE 

CHEST. 

Neoplastic growths in the lungs are usually in 
the form of nodules varying in size from that of a 
pea to a hen's egg, disserninated throughout one 
lung or both lungs, in greater or less numbers. These 
disseminated nodules, if of small size, have no well- 
marked, definite diagnostic signs. If limited to a 
lung, or if greater in number in one lung, they may 
occasion an appreciable dulness on percussion. They 
may also occasion feebleness of the respiratory 
murmur, and, owing to coexisting circumscribed 
bronchitis, moist bronchial rales may be heard at 
different points. These signs warrant a diagnosis 
when, as is usually the case, cancer is known to have 
existed elsewhere. With reference to diagnosis, it 
is to be borne in mind that, when cancer of the lung 
is secondary, both lungs are affected, and, when it is 
primary, the affection is generally unilateral. 

If there be nodules of considerable size, there will 
be well-marked dulness on percussion in different 
situations, and the signs of solidification may be 



236 DISEASES OF THE RESPIRATORY ORGANS 

present, namely, either bronchial or bronchovesicu- 
lar' respiration, either increased vocal resonance or 
bronchophony, and increased vocal fremitus. 

In some cases of unilateral carcinoma, the greater 
part, or the whole, of a lung may be infiltrated with 
the morbid growth, increasing its volume and giving 
rise to enlargement of the affected side, diminished 
respiratory movements or immobility, flatness on 
percussion, with diminished or suppressed respira- 
tory murmur, vocal resonance, and fremitus. If, as is 
usual, there be also more or less pleuritic effusion, 
the intercostal spaces may be pushed out to a level 
with the ribs. Here are the signs which denote 
chronic pleurisy with large effusion, and the differential 
diagnosis cannot be made with positiveness until the 
fluid within the chest be withdrawn, and it be found 
that, irrespective of the bulging of the intercostal 
spaces, the physical signs remain. Exploration with 
a small trocar, or hollow needle, will settle the diag- 
nosis when there is no pleuritic effusion. 

In other cases the neoplastic growth induces con- 
traction of the lung, diminishing its volume, and 
causing notable diminution of the affected side. The 
appearances on inspection are those which denote 
contraction after chronic pleurisy, and they may be 
present also in cases of fibroid phthisis or cirrhosis 
of lung. The differential diagnosis must be based 
chiefly on diagnostic points relating to the history 
and symptoms. 

Tumors within the chest, generally having their 



NEOPLASMS OF LUNG— TUMORS IN CHEST 237 

points of departure in the mediastinum, displace the 
lung in proportion to their size. They may cause 
considerable displacement of the heart, and produce 
more or less enlargement of the chest with dimin- 
ished respiratory movements. Enlargement of the 
subcutaneous veins, indicative of venous obstruction, 
is more often to he observed in solid tumors than in 
aneurism. Over *the site of the tumor there will be 
either dulness or flatness on percussion. Generally, 
respiratory sound over the tumor is wanting, vocal 
resonance and fremitus being either diminished or 
suppressed. In the neighborhood of the primary 
bronchi and over lung compressed by the tumor, 
there may be bronchial respiration, with broncho- 
phony and increased fremitus; while over portions 
of the lung not directly affected the breath sounds may 
be suppressed or stridulous as a result of bronchial 
obstructions. If the chest be enlarged, its enlarge- 
ment is not likely to be as uniform as when it is 
dilated with liquid; this is a diagnostic point. The 
tumor, or the tumors, may not be confined to one side 
of the chest. It is to be borne in mind that pleurisy 
with effusion may exist as a complication, and this 
may serve to obscure the diagnosis. 

The physical diagnosis involves differentiation from 
pericarditis with effusion and aneurisms. These 
affections are to be excluded by the absence of their 
diagnostic signs. 



238 DISEASES OF THE RESPIRATORY ORGANS 

ACUTE MILIARY TUBERCULOSIS. 

The physical condition in this affection is the pres- 
ence of a large number of the small bodies known 
as tubercles or miliary granulations, disseminated 
throughout both lungs. Bronchitis is an associated 
affection, by no means constantly present. 

If the tubercles be about equally distributed in 
the two lungs, there is no abnormal disparity of the 
resonance on percussion between the two sides of 
the chest. A comparison, also, of the two sides 
may afford no disparity as regards the respiratory 
murmur, vocal resonance, and fremitus. Moist rales, 
due to the associated bronchitis, may be present in 
different situations. A physical diagnosis, under 
these circumstances, cannot be made with positive- 
ness. Physical exploration, however, is important 
in order to exclude other affections; and the negative 
result, taken in connection with the symptoms — 
hyperpyrexia, rapid pulse, accelerated breathing, cyan- 
osis, etc. — renders the diagnosis extremely probable. 
The differential diagnosis involves discrimination from 
capillary bronchitis, and an essential fever with a 
bronchial complication. The affection has been 
repeatedly mistaken for typhoid fever. 

The tubercles may be more abundantly distributed 
in one lung. A disparity in the resonance on per- 
cussion may then be apparent, and, perhaps, an 
abnormal increase of vocal resonance and fremitus. 
The discovery of a patch of partial consolidation at the 



PHTHISIS 239 

apex of one lobe, while not evidence of miliary tuber- 
culosis, would strengthen the diagnosis by indicating 
the presence of a possible starting-point from which 
dissemination could have occurred. These signs, 
taken in connection with the symptoms, establish the 
physical diagnosis. 

PHTHISIS. 

For purposes of prognosis and treatment, the 
so-called Turban and National Association classifica- 
tions of clinical stages of tuberculosis are superior to 
any previously used (vide p. 371); from the stand-point 
of physical diagnosis, however, a simpler division, based 
more upon the pathological stage, without regard to 
the extent of the lesion, is desirable. Except for the 
area involved, the signs obtained over a small apical 
lesion may, of course, be identical with those found in 
a wide-spread affection disseminated through all lobes. 
From a clinical stand-point, however, the former case 
would be incipient, and the latter severe. 

With regard simply to the pathological stage at a 
particular point of the chest, we may conveniently 
discuss the physical diagnosis of pulmonary tubercu- 
losis under three main groupings: (1) Cases in which 
the pulmonary affection consists of small areas of 
bronchitis and peribronchial consolidation — early 
stages; (2) cases in which the affection has moderately 
or considerably progressed so that the proportion of 
healthy tissue to consolidated areas is markedly 
decreased; (3) cases in which healthy alveolar tissue 



240 DISEASES OF THE RESPIRATORY ORGANS 

is absent, or small ►in proportion to the caseating 
areas, and those in which cavities have formed. 

In cases of early phthisis the essential physical 
condition is the presence of small solidified masses, 
or nodules, the intervening vesicular structure being 
little affected. These nodules vary from the size 
of a pea to a filbert. In the vast majority of cases 
they are situated at or near the apex of either the 
right or the left lung. Generally, circumscribed capil- 
lary bronchitis coexists in proximity to the nodules. 
An intercurrent circumscribed pneumonia sometimes 
occurs, giving rise to transient solidification within 
a limited area. Dry circumscribed pleurisy situated 
over the affected portion of lung generally occurs 
from time to time. 

In the cases of a moderate or a considerable pul- 
monary affection, the difi^erence, as compared with 
the preceding group of cases, consists in the presence 
of nodules of large size, or solidification from the 
phthisical deposit extending over a space, or spaces, 
sufficient in size to give rise to well-marked physical 
signs. The solidification in these cases may be 
extended by the development of circumscribed inter- 
stitial pneumonia. The circumscribed bronchitis is 
greater, as a rule, in degree and extent; attacks of dry 
pleurisy may continue to occur, and the pleural surface 
becomes adherent. In these cases, generally, the 
affection, existing primarily in one lung, now exists in 
both lungs. The volume of the lung first affected, at 
the summit, is more or less diminished. Enlargement 



PHTHISIS 241 

of the bronchial glands is usual, and these may be so 
situated as to press upon and diminish the calibre of 
one of the primary bronchi. In some cases portions 
of lung in the neighborhood of solidified masses or 
nodules are emphysematous (vicarious emphysema). 

Cases of advanced phthisis are characterized by 
the presence of a cavity, or, commonly, of cavities, 
varying in number, size, rigidity or flaccidity of the 
walls, freedom of communication with bronchial 
tubes, and the nearness of their situation to the super- 
ficies, of the lung. In cases of progressive phthisis, in 
addition to cavities, there is more or less solidifica- 
tion from phthisical exudation and interstitial pneu- 
monia. The volume of the lung at the summit is 
often notably diminished. The pleural surfaces are 
firmly adherent. If, however, the disease has been 
retrogressive or non-progressive, there may be little 
or no solidification of lung, the cavity or cavities 
forming the only lesion. In cases of advanced phthisis, 
with very rare exceptions, both lungs are affected, 
and cavities often exist on both sides. 

The physical diagnosis in cases of early phthisis 
embraces what may be called direct and accessory 
signs. The accessory signs are those which repre- 
sent incidental affections — ^namely, circumscribed 
bronchitis, pleurisy, and pneumonia. The direct 
signs are th«ose representing the essential condition, 
namely, the solidified masses or nodules. 

In early cases the supraclavicular region may be 
found slightly retracted and the normal inspiratory 
16 



242 DISEASES OF THE RESPIRATORY ORGANS 

motion decreased on the affected side. In more 
advanced cases the retraction and Hmitation of motion 
is due to fibrous changes in the adjacent lung and 
pleura, but in the early stages there is reason to believe 
that local muscular spasm is the explanation. Pot- 
tenger, who particularly emphasizes this view, has 
also pointed out that over an incipient lesion palpa- 
tion reveals tonic contraction of the scaleni and adja- 
cent muscles, while in advanced cases atrophy of these 
muscles has occurred. 

An important direct sign is dulness on percussion. 
Slight dulness on percussion at the summit of the 
chest, in front or behind, is a highly important sign, 
taken in connection with symptoms of incipient 
phthisis. In determining that a relative dulness is 
abnormal, the student must bear in mind, in the first 
place, the normal disparity between the two sides. 
The right side at the summit is relatively somewhat 
dull on percussion in healthy persons. Due allowance 
is to be made for this normal disparity. In the second 
place it is to be borne in mind that any deformity 
affecting the symmetry of the chest will affect the 
relative resonance on the two sides; and that a devia- 
tion from symmetry attributable to the position of 
the patient will occasion a disparity on percussion. 
In the third place the rules for the practice of per- 
cussion must be kept in mind in order to avoid 
producing apparently an abnormal disparity by the 
non-observance of these rules (vide p. 89 et seq.). 
Normal resonance on percussion on the two sides is 



PHTHISIS 243 

not, however, a strong point for the exclusion of 
incipient phthisis. 

The direct respiratory sigv^s in incipient phthisis 
are more delicate diagnostic signs than is percussion. 
In the earhest cases they consist of feeble breath 
sounds and later bronchovesicular respiration. To 
these is to be added a localized interrupted or wavy 
inspiratory murmur, as an occasional sign. Of course 
familiarity with the characters of the bronchovesicular 
respiration is indispensable — the combination of the 
vesicular and the tubular quality in the inspiratory 
sound, with the pitch raised in proportion to the 
amount of tubularity, and the expiratory sound more 
or less prolonged, high, and tubular. Not infrequently 
the only appreciable morbid modification is dimin- 
ished intensity of the murmur. When this sign is 
present it is probable that the lack of intensity is the 
reason for the absence of the characters of the broncho- 
vesicular modifications, that is, the latter sign would 
have been present were the respiratory sounds more 
intense. 

The direct vocal signs in incipient phthisis are 
increased vocal resonance, increased whisper, and 
increased fremitus. The other direct signs may be 
present without an appreciable morbid increase of the 
vocal resonance or fremitus. The increased whisper 
may also be wanting, but more rarely than the two 
other vocal signs. 

In deciding on the presence or absence of each 
and all of these direct signs, it is essential to know 



244 DISEASES OF THE RESPIRATORY ORGANS 

and to judge correctly of the disparity between the 
two sides of the chest at the summit in health. Nor- 
mally the resonance or percussion at the summit 
on the right side is slightly dull as compared with 
the left side; the inspiratory sound on this side has 
some tubularity in quality, and is somewhat raised 
in pitch; the expiratory sound may be more or less 
prolonged, high, and tubular; the vocal resonance 
on the right side is always greater, the same being 
true of fremitus; the whisper is louder on the xight 
side, and the intensity of the respiratory murmur is a 
little less on this side. 

Whenever it is a question as to a small phthisical 
affection at or near the apex of the right lung, it is a 
matter of experience and judgment to decide if the dis- 
parity in respect to these points be greater than normal, 
and it is not always easy to come at once to a decision. 
From the want of a proper appreciation of the several 
points of disparity in health, it is not uncommon for an 
erroneous diagnosis of phthisis to be based thereon. 
Appreciating the normal points of disparity, it is 
obviou3ly easier to determine that the several direct 
signs of incipient phthisis are present at the left than 
at the right summit; relative dulness on percussion, 
bronchovesicular or weakened respiration, increased 
vocal resonance, whisper, and fremitus, at the left 
summit are, of course, always abnormal. 

Corroborative evidence of incipient phthisis may 
be obtained by the presence of accessory signs. These 
are: (1) Fine bubbling or the so-called subcrepitant 



PHTHISIS 245 

rale at the summit on one side. This sign denotes a 
circumscribed capillary bronchitis, and this, at the 
summit on one side, is usually associated with phthisis. 
(2) A crepitant rale at the summit on one side denotes 
a circumscribed pneumonia which is usually second- 
ary to phthisis. (3) A pleuritic friction sound limited 
to the summit on one side is evidence of a dry circum- 
scribed pleurisy which occurs often in the early stage 
of phthisis. (4) Indeterminate rales, crumpling and 
crackling, are significant of phthisis if limited to the 
summit on one side. These rales, it is to be recollected, 
are sometimes found in healthy persons on forced 
breathing, especially if the binaural stethoscope be 
employed. If they be normal they are found on both 
sides. The accessory signs are not sufficient for a 
positive diagnosis if they exist alone; but they are 
to be considered as corroborating the evidence derived 
from the direct signs, together with the symptoms 
and history. It is of service often in bringing out the 
rales to cause the patient to cough at the end of 
expiration and then inhale deeply. 

As regards differential diagnosis, the affections 
with which incipient phthisis is likely to be con- 
founded are chronic bronchitis and moderate emphy- 
sema. With respect to the first of these affections — 
namely, bronchitis — it must be remembered that 
from a physical stand-point these early stages of 
tuberculosis are merely areas of bronchitis, with 
associated small bronchopneumonia nodules, due to 
a special organism. The tendency of that organism 



246 DISEASES OF THE RESPIRATORY ORGANS 

to select certain areas of the lung; the chronicity of 
the process, and its slow extension so that the signs 
have a localized distribution, are more important 
characteristics than the actual signs obtained over 
any given point of the chest. Slight dulness with 
subcrepitant rales, and decreased or bronchovesicular 
breath sounds limited to one apex are characteristic 
of tuberculosis, while the same signs limited to the 
bases suggest chronic passive congestion of the lung 
from mitral disease; or if present uniformly throughout 
the chest are usually indicative of an acute broncho- 
pneumonia. In cases of considerable duration the 
tendency of tubercular consolidations either to caseate 
or else heal by fibrosis, instead of resolution, leads to 
such signs as altered resonance, modified voice and 
breath sounds which are not present in simple chronic 
bronchitis. 

The physical signs in cases of moderate emphysema 
sometimes lead to the error of supposing this affection 
to be phthisis. Owing to the relatively greater inten- 
sity of the resonance on percussion at the left summit, 
dulness is thought to exist at the right summit ; and a 
prolonged expiration, with the normally greater vocal 
resonance at the right summit, are regarded as signs of 
phthisis. This error may be avoided by a careful 
study of the signs of emphysema, and the normal dis- 
parity in respiration, vocal resonance, and fremitus, 
existing between the two sides of the chest. 

The physical diagnosis of a phthisical affection 
which is considerable or moderate in amount, is, in 



PHTHISIS 247 

most cases, an easy problem. Inspection often fur- 
nishes marked signs. The upper anterior portion 
of the chest on one side is depressed or flattened, 
and the superior costal movements of respiration are 
diminished, the chest elsewhere being symmetrical in 
both size and motions. There is more or less marked 
dulness on percussion at the upper part of the chest 
on the affected side. Sometimes the diminished reso- 
nance is tympanitic in quality (tympanitic dulness) 
without the existence of cavities, the resonance being 
transmitted from the primary and secondary bron- 
chial tubes. The respiration is either bronchial or 
bronchovesicular approximating more or less to the 
bronchial. Occasionally, however, the respiratory 
sounds are too feeble for their characters to be appre- 
ciated. There is either bronchophony, or the vocal 
resonance is notably increased without the broncho- 
phonic characters. The whisper is either distinctly 
bronchophonic or it is notably increased in intensity, 
high in pitch, and tubular in quality. Vocal fremitus 
is often increased. Moist bronchial rales, coarse or 
fine, are generally present. With these diagnostic 
signs on one side, the signs of a smaller amount of 
disease are generally present on the other side. 

In some cases of a moderate phthisical affection, 
the judgment may be confused by the resonance on 
percussion being increased or vesiculotympanitic on 
the affected side. This sign denotes the coexistence 
of emphysematous lobules (vicarious emphysema) 
developed in the progress of phthisis. The diagnosis 



248 DISEASES OF THE RESPIRATORY ORGANS 

of the latter affection is then to be based on the signs 
obtained by auscuUation. 

In advanced phthisis the physical diagnosis of the 
disease is easy. The signs distinctive of this stage 
of the disease are those which denote pulmonary 
cavities — namely, tympanitic resonance on percus- 
sion within a circumscribed space; cracked-metal or 
amphoric resonance; cavernous respiration; cavernous 
whisper and sometimes pectoriloquy; amphoric respi- 
ration and voice, and gurgling {vide Chapter VI for 
description of these signs). 

The cavernous signs are generally associated with 
the signs of solidification. In some cases, however, 
in which the disease has been non-progressive and 
retrogressive, the cavernous signs are present without 
the signs which denote solidification of lung. 

FIBROID PHTHISIS— INTERSTITIAL PNEUMONIA, 
OR CIRRHOSIS OF LUNG. 

In this affection the physical conditions are, 
solidification from hyperplasia of the interstitial 
pulmonary tissue, dilatation of bronchial tubes 
(bronchiectasis), and diminished volume of the lung 
affected. The affection, as a rule, is either limited 
to, or especially marked on, one side. The whole of 
a lung, or only a portion of it, may be affected. 
Bronchitis always coexists. 

There is notable dulness on percussion, the dimin- 
ished resonance being sometimes tympanitic. The 



DIAPHRAGMATIC HERNIA 249 

degree of resonance may vary at different exami- 
nations, owing to differences in the amount of morbid 
products within the bronchial tubes. The respiration 
is bronchial, or bronchovesicular. At times, from 
obstruction of bronchial tubes, it may be suppressed. 
Bronchophony and increased vocal resonance are the 
vocal signs, together with the corresponding whis- 
pering signs. The side of the chest which is chiefly 
or exclusively affected becomes contracted either 
entirely or in part, resembling in this respect the 
appearances after chronic pleurisy. The heart is 
frequently drawn toward the affected side. 

With these signs the affection is to be differen- 
tiated from the ordinary form of phthisis by reference 
to points pertaining to the symptoms and history. 



DIAPHRAGMATIC HERNIA. 

The presence of more or less of the abdominal 
viscera within the thoracic cavity in consequence 
of a congenital deficiency of a portion of the dia- 
phragm, or perforation from accidents, or enlarge- 
ment of the natural openings, gives rise to certain 
anomalous signs — namely, a tympanitic resonance, 
variable at different times owing to differences as 
regards the quantity of gas within the viscera; 
absence of the respiratory murmur from the base 
of the chest upward, the height proportional to the 
space occupied by the abdominal organs, and the 



250 DISEASES OF THE RESPIRATORY ORGANS 

intestinal sounds emanating from within the chest, 
not conducted from below. 

This extremely rare affection can only be con- 
founded with pneumothorax, or a pleural effusion, 
when the stomach is full of food. 

The use of the x-ray is invaluable in this condition, 
and gives positive evidence as to the physical rela- 
tions of the diaphragm and the abdominal and 
thoracic viscera. 



CHAPTER VIII. 

THE PHYSICAL CONDITIONS OF THE HEART 

IN HEALTH AND DISEASE. THE HEART 

SOUNDS AND CARDIAC MURMURS. 

Physical conditions of the heart in health: Boundaries of the 
precordia— Normal situation of the apex beat — Boundaries of 
the deep and of the superficial cardiac space — Relations of the 
aorta and the pulmonary artery to the walls of the chest — 
The heart sounds — Characters distinguishing the first and the 
second sound — Mechanism of the production of the heart 
sounds — Auscultation of the pulmonic and the aortic second 
sound separately — Movements of the auricles and ventricles 
in relation to each other — Physical conditions of the heart in 
disease: Enlargement of the heart — Hypertrophy and dilata- 
tion — Abnormal impulses of the heart, and modifications of the 
apex beat — Valvular lesions — Roughness of the pericardial sur- 
faces — Liquid within the pericardial sac — Abnormal modifica- 
tions of the heart sounds — Reduplication of heart sounds — 
The pulse — Frequency of pulse — Regularity of pulse— Size of 
pulse — Rapidity of pulse — Tension of pulse — Character of 
arterial wall — Capillary pulsation — Pulsation of the cervical 
veins— Cardiac murmurs — Normal and abnormal blood currents 
within the heart, and their relations with the heart sounds — 
Mitral direct murmur — Flint murmur — Mitral regurgitant 
murmur — Mitral systohc murmurs of functional and cardio- 
respiratory origin — Aortic direct murmur — Aortic regurgitant 
murmur — Aortic diastolic non-regurgitant murmur — Coexisting 
endocardial murmurs — Tricuspid direct murmur — Tricuspid 
regurgitant murmur — Pulmonic direct murmur — Pulmonic 
regurgitant murmur — Facts of practical importance in relation 
to endocardial murmurs — Pericardial or friction murmur. 

Before entering upon the study of the physical 
diagnosis of the disease of the heart the student 



252 PHYSICAL CONDITIONS OF THE HEART 

must be familiar with its anatomy and physiology. 
The plan of this work embraces the anatomical rela- 
tions of the heart and the space which it occupies 
within the chest, as physical conditions of health 
determinable by normal signs, together with the 
heart sounds. Having briefly stated these condi- 
tions of health, the morbid physical conditions which 
may be ascertained by percussion, auscultation, and 
other methods of physical exploration, will be con- 
sidered. 

THE PHYSICAL CONDITIONS OF THE HEART 
IN HEALTH. 

The Precordia. — The area on the surface of the chest 
corresponding to the space which the heart occupies 
within the chest is the precordial rpgion, or the pre- 
cordia. The upper, lower, and two lateral boundaries 
of this region must be memorized. The upper bound- 
ary is the third rib, the lower is a horizontal line 
passing through the fifth intercostal space; the left 
lateral boundary is at or a little within the left mid- 
clavicular line, and the right lateral boundary is 
represented by a vertical line situated about a finger's 
breadth to the right of the right margin of the ster- 
num. As the volume of the heart varies, within 
certain limits, in different healthy persons, the bound- 
aries of the precordia are, of course, not always exactly 
the same. The foregoing statements are sufficiently 
accurate for practical purposes. 

The horizontal line representing the lower bound- 



THE HEART IN HEALTH 253 

ary of the precordia intersects the point where the 
apex beat of the heart is felt. In most healthy 
persons the apex beat is felt, and frequently seen, 
in the fifth intercostal space, a little within the mid- 
clavicular line. This is assuming the persons to be 
sitting or standing. In recumbency on the back the 
beat sometimes rises to the fourth intercostal space, 
and it is sometimes found in the fourth space in the 
sitting or standing position of the body. The distance 
from the midclavicular line varies in different healthy 
persons; it is sufficiently accurate to say it is a little 
within that line (Fig. 14). 

In changing a patient from the left lateral recum- 
bent to the right lateral position, it may be determined 
by palpation and percussion that the apex of the 
heart moves f to 1| inches to the right in healthy 
people. 

The use of the orthodiagraphic method of examin- 
ing the heart in action has brought about a read- 
justment of our ideas as to the probable accuracy 
of topographical percussion of the heart. Although 
percussion will still be considered a necessary and 
useful method of examining the heart, the highest 
standard of accuracy will demand the use of the 
orthodiagram. 

The Apex Beat. — In speaking of the apex of the 
heart we refer to the most lateral point at which a 
definite impulse can be felt; in sharp contrast to the 
point of maximal impulse (P. M. I.) which is inside 
the true apex. 



254 PHYSICAL CONDITIONS OF THE HEART 

The force of the apex beat varies much in different 
healthy persons, owing to other causes than the power 
of the heart's action, such as the amount of muscular 
substance and fat in that situation, the width of the 
intercostal space, the convexity of the chest, the rela- 
tion to the left lung, etc. Allowance is to be made 
for these variations in determining the abnormal 
modifications of the force of the beat. 

The Superficial and Deep Cardiac Space. — Within a 
portion of the precordia the heart is uncovered by lung, 
and in the remaining portion lung intervenes between 
the heart and the walls of the chest. The former of 
these portions is called the superficial and the latter 
is called the deep cardiac space. The superficial 
cardiac space on the right side extends to the median 
line. On the left side the lung recedes at a point on 
the median line on a level with the cartilage of the 
fourth rib, and the anterior border of the upper lobe 
makes an outward curve, returning inward at or near 
the apex of the heart. This leaves the heart uncovered 
within an area which, for practical purposes, may be 
represented by a right-angled triangle, the hypotenuse 
extending from the median line on a level with the 
costal cartilage of the fourth rib to the apex of the 
heart; the right angle formed by the median line and 
the horizontal line which forms the low^ei* boundary 
of the precordia (Figs. 14 and 15). 

The lateral limit of the superficial cardiac space may 
be easily defined by percussion. It is only necessary 
to ascertain the curved line formed by the receding 



THE HEART IN HEALTH 



255 



anterior border of the upper lobe of the left lung. 
A distinct, although not great, dulness on percussion 
marks this border of the lung. The border of the 
lung is as distinctly marked by the abrupt diminu- 




FiG. 14 



tion of the vocal resonance, if auscultation be made 
with the stethoscope. Percussion of the right border 
of the superficial cardiac space is unsatisfactory 
because the sternum not only contributes its own reso- 
nance but also conducts the percussion stroke later- 



256 PHYSICAL CONDITIONS OF THE HEART 

ally to lung not immediately beneath the finger (vide p. 
29). The area of flatness obtained, therefore, is 
smaller than the true superficial cardiac space, being 
bounded on the right by the left sternal margin. 




Fig. 15 



This lack of power to determine accurately the super- 
ficial cardiac area is not as important as one might 
suppose. For the right border of cardiac flatness is 
shifted toward the right when the superficial area is 



THE HEART IN HEALTH 257 

enlarged by cardiac dilatation or pericardial effusion. 
In other words, the area of flatness is an indication 
of an increased or decreased superficial space, even 
though it never corresponds exactly to the size of 
that space. The outer boundaries of the deep cardiac 
space may also be determined by percussion. Distinct, 
though slight, dulness marks the limits of the pre- 
cordia. Defining thus the boundaries of the pre- 
cordia and of the superficial cardiac space in healthy 
persons makes a good practical exercise in percussion. 
Distinct, though slight, dulness may usually be made 
out in the fourth space to the right of the sternum as 
far as three-quarters of an inch from the sternal border. 
Relations of the Aorta and Pulmonary Artery to the 
Wall of the Chest. — The base of the heart, especially 
in connection with auscultatory signs, is generally 
considered to be at the second intercostal space near 
the sternum, although in reality it lies at the level of 
the third intercostal space (Fig. 16, p. 258). In the 
right and left second intercostal spaces sounds pro- 
duced at the aortic and the pulmonic orifice are 
best studied, either in health or disease. With refer- 
ence to these sounds, the anatomical relations of the 
aorta and the pulmonary artery to the right and the 
left second intercostal space are of importance. If the 
stethoscope be applied in the second intercostal space 
on the right side, close to the sternum, it is very near 
the aorta, and sounds produced at the aortic orifice 
are transmitted along the vessel and best heard in 
this situation. If the stethoscope be applied in the 
17 



258 PHYSICAL CONDITIONS OF THE HEART 

second intercostal space on the left side^ it is very near 
the pulmonary artery (vide Figs. 14 and 16), and here 
the sounds produced at the pulmonic orifice are loudest. 




Fig. 16. — Topography of the heart valves. P, pulmonary; 
A, aortic; M, mitral; T, tricuspid valve. They are more widely 
separated than usually found; the condition being probably due 
to cardiac dilatation. (Norris and Fetterolf.) 



THE HEART IN HEALTH 



259 




Fig. 17. — Frontal section of the thorax, showing right auricle, 
left ventricle, the pulmonary artery cut across, and the ascending 
aorta. The fissure between right upper and middle lobe is 
incomplete. (Norris and Fetterolf.) 



260 PHYSICAL CONDITIONS OF THE HEART 

The Heart Sounds. — It is customary to consider the 
heart sounds as two in number, and to distinguish 
them as the first (S i) and the second sound (S ii). 
The characters which distinguish the heart sounds in 
health are to be studied preparatory to the study of 
the abnormal modifications, which are important 
physical signs of disease. It is essential to be able 
always to make the distinction between the so-called 
first and the second sound in order to connect with 
them separately cardiac murmurs. The conven- 
tional use of the term heart sounds, as distin- 
guished from cardiac murmurs, must be borne in 
mind. The cardiac murmurs are adventitious sounds; 
they are never merely abnormal modifications of the 
heart sounds, but they are new sounds added to or 
replacing these. 

Considering the heart sounds as two in number, 
these follow in a certain rhythmical order, and, in 
health, this suffices for the recognition of each. The 
sounds follow each other after an interval which is 
just appreciable, this interval being the short pause 
of the heart. After the occurrence of both an inter- 
val is readily appreciable, called the long pause of the 
heart. It is not necessary to carry in the memory the 
exact relative duration of each of the two sounds and 
each of the two intervals. It is sufficiently exact to 
say that, with the ear or stethoscope applied over 
the situation of the apex beat, the first sound is longer 
than the second, louder, lower in pitch, and has a 
quality which may be called booming. Per contra, 



THE HEART IN HEALTH 261 

the second sound is shorter, weaker, higher in pitch, 
and has a quahty which may be called valvular or 
clicking. Aside from the relative length, the other 
characters are more or less marked in different healthy 
persons. 

A third heart sound is heard at the apex in about 
65 per cent, of people under forty when they are 
placed in the recumbent left lateral positions {vide 
Thayer, Arch. Int. Med., 1909, vol. iv, No. 4). 
This heart sound which is softer and of lower pitch 
than the second sound, occurs early in diastole and 
follows the second sound of the heart by about one- 
tenth to two-tenths second. This sound seems to be 
due to the sudden tension of the auriculoventricular 
valves, as a result of the first rush of blood from auricle 
into ventricle, in diastole. It is known as the proto- 
diastolic third sound to distinguish it from the so-called 
presystolic third which is sometimes heard at the time 
of auricular systole {vide Fig. 22, p. 297). 

These distinctive characters of the first and second 
heart sounds are apparent when the ear or stethoscope 
is applied over the apex. At the base of the heart, 
that is, in the second intercostal space near the ster- 
num, the characters of the first sound are not the 
same as over the apex. The second sound in this 
situation is louder than the first. Moreover, the first 
at the base may not be longer than the second; it 
loses more or less of its booming quality, the pitch 
remaining lower than that of the second sound. 
Removing the ear or the stethoscope a certain dis- 



262 PHYSICAL CONDITIONS OF THE HEART 

tance from the apex in any direction, occasions similar 
changes in the character of the first sound. The inter- 
position of several thicknesses of a napkin has the 
same effect. 

From the differential characters over the apex, 
and the rhythm alone in other situations, there is no 
difficulty in distinguishing the first from the second 
sound in health. In cases of disease, however, owing 
to disturbance of the rhythm, modifications of the 
characters of the first sound, and the absence some- 
times of one of the sounds, other means of recog- 
nition must be resorted to. If the apex beat can 
be felt, this offers a ready way — the sound which is 
synchronous with the apex beat is, of course, the 
first sound. This mode is not always available, inas- 
much as the apex beat cannot always be felt. Another 
mode is always available — namely, feeling the carotid 
pulse. The carotid pulse is synchronous with the first 
sound, whereas there is a slight interval between this 
sound and the radial pulse, so that the latter is an 
unreliable guide. 

The Production of the Heart Sounds. — The second 
sound is produced by the sudden tension on the aortic 
and pulmonic valve segments as they close behind 
the blood which has just been forced into the arteries. 
This closure is caused by a retrograde movement of 
the blood in the aorta and pulmonary artery, directly 
the ventricular systole is ended. The retrograde 
movement is due to the recoil of the coats of the 
arteries which have been dilated by the column of 



THE HEART IN HEALTH 263 

blood moving onward during the ventricular systole. 
This recoil causes sudden tension on the aortic and 
pulmonic segments which produces a sound, just as 
that produced by suddenly stretching a piece of 
cloth held slack between the hands. 

The mechanism of the first sound is less simple. 
This sound is in part due to the forcible tension of 
the auriculoventricular valves, caused by the systole 
of the ventricles. In this way is produced a valvular 
element of the systolic sound. The contraction of 
the heart muscle itself contributes the more important 
part of this heart sound in health. To this element 
of contracting muscle the first sound is indebted 
for its greater intensity, its length, and its booming 
quality. The valvular element of the first sound is 
weaker than the second sound, partly because the 
vibrations have to be transmitted farther before 
reaching our ears, and partly because the tension on 
the auriculoventricular valves is not as sudden as in 
the case of the semilunars. 

The Second Sounds in Health. — With reference to 
important bearing on auscultation in disease, the 
second sound is to be studied as produced at the aortic 
and the pulmonic orifices separately. Recalling the 
anatomical relations of the aorta and the pulmonary 
artery to the wall of the chest, if the stethoscope be 
applied in the second intercostal space on the right side 
close to the sternum, the characters of the diastolic 
sound are derived chiefly from the aortic valve, and if 
the stethoscope be applied in the second intercostal 



264 PHYSICAL CONDITIONS OF THE HEART 

space on the left side close to the sternum, the char- 
acters of the diastolic sound are derived chiefly from 
the pulmonic valve. The correctness of this statement 
is proved by differences in the characters of the sound 




Fig. 18. — Showing the areas in which the various heart sounds 
are best heard in health. A is the area for the aortic valve; P, 
that for the pulmonary valve; T, for the tricuspid valve; and M, 
for the mitral valve. The pulmonary circle is a little high. 
(Hare.) 



on two sides in health, and by the modification in 
cases of disease. In health the aortic diastolic sound 
is somewhat louder, higher in pitch, and the valvular 



THE HEART IN HEALTH 265 

quality more marked than the pulmonic diastolic 
sound. 

In patients under twenty years of age the pul- 
monary second sound may be found to be equal to, 
or louder than, the aortic second sound. Over the 
age of twenty, and usually to an increasing degree 
with advancing years, the aortic second sound is 
louder than the pulmonary second sound, owing, in 
all probability, in the main, to the increasing tension 
or blood-pressure in the systemic arteries at maturity 
and after. 

The student should verify these points of difference 
by the study of the second sound in the pulmonic 
and aortic areas. In order for the comparison to be 
a fair one in health, and available in the diagnosis of 
disease, the normal anatomical relations to the wall 
of the chest, of the aorta, and pulmonary artery 
must be preserved. These relations are affected b}' 
changes in the symmetry of the chest, and sometimes 
by enlargement of the heart. The lungs must also 
be free from disease; otherwise the location of the 
heart or the transmission of the sounds may be 
abnormal. 

In the account of the mechanism of the production 
of the heart sounds (vide p. 262) it was stated that 
the first sound consists of a valvular element and 
an element of muscular contraction. This valvular 
element is a twofold sound, that is, it is a combi- 
nation of a sound produced by the mitral and a 
sound produced by the tricuspid valve. These 



266 PHYSICAL CONDITIONS OF THE HEART 

two synchronous valvular sounds may be studied 
separately in health, and their abnormal modifica- 
tions constitute diagnostic signs in cases of disease. 
The two valvular sounds may be designated the mitral 
and the tricuspid sounds. 

The second sound of the heart, as has been seen, is 
resolvable into two distinct sounds. Hence the num- 
ber of distinct heart sounds is, in reality, four, two of 
which are diastolic and two systolic — namely, the mitral, 
the tricuspid, the aortic, and the pulmonic. Each of 
these four sounds may be studied separately in health 
and disease. The abnormal modifications of each fur- 
nish important information in diagnosis. 

In health the sound of muscular contraction com- 
bined with the mitral valvular sound is heard in the 
region of the apex beat. 

The tricuspid valvular sound is heard best at the 
end of the sternum or just to the left of this point. 

In the pages which follow I shall sometimes refer to 
the first and the second sound in the singular number, 
it being understood that the first sound embraces two, 
and the second two, components; and at other times 
I shall refer to the sounds separately, which are com- 
bined in the two sounds. 

The order of the succession of the movements of 
the auricles and of the ventricles is to be kept in 
mind {vide diagram, p. 297). Points of special impor- 
tance are the contraction of the auricles in the latter 
part of the long pause of the heart, preceding the ven- 
tricular systole, and the twisting of the heart from left 



THE HEART IN DISEASE 267 

to right in the systole^ this movement being reversed 
in the diastole. In these systohc and diastoUc twist- 
ing movements the visceral and parietal portions of 
the pericardium move upon each other, in health 
noiselessly, owing to their smoothness and moisture. 
The movements occasion an auscultatory sign — 
namely, a friction murmur — when the surfaces are 
roughened by the presence of fibrin. Other points 
are the size of the pericardial sac, that is, its capa- 
bility of holding when filled, but not dilated, from 15 
to 20 ounces of liquid, and its attachment, not to the 
base of the heart, but to the vessels above the base. 

PHYSICAL CONDITIONS OF THE HEART IN 
DISEASE. 

The physical conditions of the heart in disease, 
which are determinable by physical exploration, are: 
(1) Enlargement of the heart; (2) abnormalities in 
position or force of the apex beat (those of rhythm and 
rate being considered later, p. 283); (3) valvular 
lesions; (4) roughness of the pericardial surfaces; 
and (5) liquid within the pericardial sac. Having 
considered these conditions, an account of abnormal 
modifications of the heart sounds and cardiac murmurs 
will conclude this chapter. 

Enlargement of the Heart. — Enlargement of the heart 
may be slight, moderate, great, or very great. In 
cases of very great enlargement, the space within 
the chest which the heart occupies may be from four 



268 PHYSICAL CONDITIONS OF THE HEART 

to five times larger than in health. The situation 
of the base of the heart remains but little, or not at 
all, changed in cases of enlargement; the increased 
space which the heart occupies is therefore down- 
ward and laterally. The increased space extends 
much more to the left than to the right; the left border 
of the heart, in proportion to the enlargement, is car- 
ried beyond the midclavicular line on the left side, 
whereas the right border is carried comparatively 
but little beyond the normal right lateral boundary 
of the precordia even when the enlargement is very great. 

The cardiac dulness may be increased in all direc- 
tions or only in one direction. We naturally attribute 
a dislocation of the left border of cardiac dulness to 
the left, to enlargement of the left ventricle; a disloca- 
tion of the right border to the right, to enlargement of 
the right ventricle and right auricle; an increase upward, 
to dilatation of the left auricle or of the great vessels. 
In dilatation of the right auricle and ventricle in 
tricuspid insufficiency the cardiac dulness may extend, 
in third and fourth spaces, as far to the right as it is 
found normally to the left of the sternum. 

The superficial cardiac space is enlarged in propor- 
tion to the enlargement of the heart; the organ pushes 
to the left the receding anterior border of the upper 
lobe of the left lung, and is proportionately in contact, 
uncovered of lung, with the wall of the chest. The 
apex of the heart is lowered in proportion to the 
enlargement of the left ventricle, and it is carried 
more or less to the left of its normal situation. It 



THE HEART IN DISEASE 269 

may be lowered to the sixth, seventh, eighth, or ninth 
intercostal space. The enlargement of the heart is 
rarely equal in all its parts. The ventricular enlarge- 
ment may be entirely, or chiefly, of either the right or 
the left ventricle. Enlargement of the right ventricle 
tends to carry the right side of the heart more to 
the right than when the left ventricle is enlarged. 
The situation of the apex is also affected by the 
parts of the heart in which the enlargement pre- 
dominates. The apex is carried farther to the left 
of its normal situation, other things being equal, when 
the enlargement predominates on the right side of the 
heart; and it is lowered, without being carried far to 
the left, when the enlargement of the left ventricle 
predominates. The apex of the organ, in cases of 
considerable, or of great enlargement, becomes changed 
in form; it is rounded or blunted. This change is 
most marked when enlargement of the right ventricle 
predominates. 

Enlargement of the heart may be due, entirely 
either to hypertrophy or to dilatation (simple hyper- 
trophy and simple dilatation). If, however, the 
enlargement be sufficient to occasion notable dis- 
turbance of the circulation, both these forms of 
enlargement are combined, but, as a rule, one or the 
other form predominating; so that, of the cases of 
diseases of the heart which come under medical treat- 
ment, the majority are cases of either enlargement 
with predominant hypertrophy, or enlargement with 
predominant dilatation. 



270 PHYSICAL CONDITIONS OF THE HEART 

These widely different physical conditions are 
concerned especially in the abnormal impulses and 
modifications of the apex beat as well as, also, the 
heart sounds. 

Abnormal Impulses of the Heart, and Modifications of 
the Apex Beat. — The abnormal situation of the apex 
of the heart when enlarged has been stated. Gener- 
ally the situation is determinable by the apex beat. 
It has been seen that in health the beat is sometimes 
not appreciable by the touch, owing to the thickness 
of the soft parts, and the conformation of the thorax, 
and, for these reasons, the force of the beat varies 
much in different healthy persons. Exclusive of 
normal variations, the beat is generally strong and 
prolonged, in proportion as the heart is enlarged by 
hypertrophy. There are exceptions to this statement, 
which are to be explained by the altered form of 
the apex; when it loses its pointed form it does not 
so readily come into contact with the walls of the 
chest in an intercostal space, and hence the beat 
may be weak, although the ventricular systole be 
abnormally strong. On the other hand, the apex 
beat is weakened by dilatation, and it may be want- 
ing, as a result of diminished strength of the systole 
of the ventricles. The apex beat is also abnormally 
weak in fatty degeneration and softening of the heart, 
as well as in functional debility of the organ, incident 
to other diseases than those of the heart. 

If there be considerable or great enlargement, the 
heart being in contact with the wall of the chest over 



THE HEART IN DISEASE 271 

a larger area than in health, impulses other than 
the apex beat are generally apparent to the eye and 
touch. Not infrequently impulses are appreciable in 
each intercostal space between the situation of the 
apex and the base of the heart. These abnormal 
impulses are felt to be strong in proportion as the 
enlargement is due to hypertrophy, and weak in 
proportion as dilatation predominates. Enlargement 
seated in the right ventricle causes an impulse in the 
epigastrium which is strong or weak in proportion 
as hypertrophy or dilatation predominates. 

Cardiac impulses are felt and seen in abnormal 
situations when the heart is removed from its normal 
situation by the pressure of an aneurism, or other 
tumor, by pleuritic effusion, hydroperitoneum, etc. 
The error of mistaking for a cardiac impulse the 
pulsation of an aneurismal tumor is to be avoided. 
Another error is to be avoided — namely, mistaking 
abnormal impulses due to the heart being uncovered 
of lung, by shrinking of the latter in certain pul- 
monary affections, for impulses denoting enlargement 
of the heart. In cases of enlargements by hyper- 
trophy, a heaving movement of the whole precordia 
is sometimes felt when the hand is ■ applied to the 
chest. A violent shock is sometimes felt by the 
hand applied to the precordia, but without a sense 
of increased muscular power, in cases of purely func- 
tional disorders of the heart. Because of pericardial 
adhesions, or due to enlargement and displacement 
of the heart, a systolic retraction may be seen where 



272 PHYSICAL CONDITIONS OF THE HEART 

we should expect a systolic impulse^ and a diastolic 
impulse or retraction may appear, and demand close 
attention to be located with reference to its place 
in the cardiac cycle. 

Valvular Lesions. — The lesions affecting the valves 
of the heart may be distributed into three groups, as 
follows: (1) Lesions which diminish more or less the 
size of the orifices, or obstructive lesions; (2) lesions 
which render the valves more or less incompetent and 
permit regurgitation, or regurgitative lesions; and (3) 
lesions whibh roughen the surfaces; over which the blood 
moves without occasioning either obstruction or 
regurgitation. The latter may be distinguished as 
innocuous lesions, giving rise to no pathological effects, 
although represented by cardiac murmurs. 

It is to be borne in mind that in the great majority 
of cases valvular lesions are seated in the left side of 
the heart, that is, they are either mitral or aortic. 
Tricuspid and pulmonic lesions are comparatively 
rare, and they are generally congenital. Not infre- 
quently mitral and aortic lesions coexist, and there 
may be coexisting lesions at all the orifices of the 
heart. 

Valvular lesions are represented by cardiac mur- 
murs. By means of the murmurs the existence of 
lesions is known, their situation at the different orifices 
may be ascertained, and, generally, it is practicable 
to determine whether they occasion obstruction or 
regurgitation, or both. These several points of 
inquiry will be considered presently under the head- 
ing Cardiac Murmurs. 



THE HEART IN DISEASE 273" 

Roughness of the Pericardial Surfaces. — In place of 
the smoothness of the pericardial surfaces in health, 
which permits their movements upon each other 
noiselessly, the presence of the inflammatory product, 
fibrin and, in some rare instances, morbid growths, 
occasion an adventitious sound or murmurs, just as 
in the case of dry, fibrinous pleural exudates. These 
will be considered under Pericarditis (vide p. 318). 

Liquid within the Pericardial Sac. — ^More or less liquid 
transudes into the pericardial sac in cases of general 
dropsy or anasarca, but rarely in very large quantity. 
Liquid effusion occurs in acute pericarditis, and in 
this affection the sac may become filled with serous 
or purulent liquid. In some cases of chronic peri- 
carditis the sac is greatly dilated by liquid, the quan- 
tity amounting to two quarts or even more. 

When the pericardial sac is filled with liquid, with- 
out being dilated, it forms a pear-shaped tumor within 
the chest, the base of which is at the sixth or seventh 
intercostal space; the apex rises nearly to the sternal 
notch; the left lateral border is considerably beyond 
the nipple, and the right lateral border is more or 
less beyond the right margin of the precordia. The 
anterior portion of the filled pericardium is mostly 
uncovered by lung and in contact with the wall of 
the chest. Within this area there is either notable 
dulness or flatness on percussion with an extraordi- 
nary increased sense of resistance, and absence of 
respiratory murmur and of vocal resonance. By 
means of these signs the boundaries of the pyriform 
18 



274 PHYSICAL CONDITIONS OF THE HEART 

tumor may be readily delineated on the surface of 
the chest. The difference in form and situation of 
the area of dulness or flatness on percussion in cases 
of large pericardial effusion, from the area in cases 
of enlargement of the heart (vide pp. 267 and 322), is 
of great value in the differential diagnosis. 

When the pericardial sac is partially filled with 
liquid, the same signs are present, but within an area 
of less extent, and the configuration of the pyriform 
tumor is wanting. 

In cases of chronic pericarditis with a large accu- 
mulation of liquid, the pericardial sac is dilated so 
that its lateral boundaries may extend nearly to the 
axillary and infra-axillary regions, and the pyriform 
shape is usually lacking, the outline being more nearly 
globular. Under these circumstances flatness on per- 
cussion, absence of respiratory murmur and of vocal 
resonance are present over the greater part of the 
anterior aspect of the chest. 

ABNORMAL MODIFICATIONS OF THE HEART 

SOUJTDS. 

In order to appreciate the abnormal modifications 
of the heart sounds, their normal characters are to be 
kept in mind (vide p. 260), and the student must 
be practically familiar with them. The modifica- 
tions relate to the three components of the systolic 
sound and to the two components of the diastolic 
sound, collectively and separately. 



MODIFICATIONS OF THE HEART SOUNDS 275 

The muscular element of the first sound, as heard 
over the apex, is intensified in hypertrophy of the 
heart. This sound is not only notably loud, but 
prolonged, and its booming quality is marked. The 
valvular element of the sound — namely, the mitral 
and the tricuspid — are also more or less increased in 
intensity. 

In some cases of violent palpitation the valvular 
components of the first sound are intensified, although 
the muscular element is comparatively weak. I 
suppose the explanation to be as follows: The ven- 
tricles contract with a kind of spasmodic action upon 
a small quantity of blood. Under such circumstances, 
instead of meeting with resistance from the beginning 
of systole, the contraction of the ventricle is unim- 
peded until its cavity has decreased to the volume 
of the unusually small amount of blood present. At 
that point the sudden resistance causes an extremely 
abrupt rise of pressure and tension on the auriculo- 
ventricular valve. The resultant shock is analogous 
to that experienced by one who walks down an 
unexpected step. Hence the valvular sounds are 
intensified, while the sound of muscular contraction 
may be feeble or wanting. 

The muscular element over the apex is w^eakened 
or lost, as an effect of those affections of the heart, 
which diminish the power of the ventricular systole. 
These affections are enlargement from dilatation, 
atrophy, fatty degeneration, myocarditis, obstruction 
of the coronary arteries, and softening. The systolic 



276 PHYSICAL CONDITIONS OF THE HEART 

valvular elements are also more or less weakened, 
but in a less degree than the sound of impulsion. 
The loss of the sound of contraction over the apex 
renders the so-called first or systolic sound of the 
heart short and valvular in quality. 

Liquid effusion within the pericardium renders the 
sound of impulsion over the apex more or less weak. 
If the liquid effusion be large, only the valvular 
elements — namely, the mitral and tricuspid — are 
appreciable. Diminished power of the hearths action 
from other than cardiac diseases involves weakness 
of all the heart sounds, but more especially of those 
of lower pitch. 

Abnormal modifications of the second sound relate 
to the aortic and pulmonic sounds considered sepa- 
rately. Whenever, from mitral obstructive or 
regurgitant lesions, or both combined, or from 
obstruction at the aortic orifice, the quantity of 
blood propelled by the left ventricle into the aorta 
is diminished, the recoil of the arterial coats, after 
the ventricular systole, is lessened; consequently, 
the aortic segments expand with less force, and the 
aortic sound is weakened. Diminished intensity of 
the aortic sound here represents a decreased arterial 
pressure due to abnormal diminution of the quantity 
of blood propelled into the systemic arteries by the 
systole of the left ventricle, and this diminished inten- 
sity of sound is, in a measure, a criterion of the 
amount of mitral obstruction or mitral regurgitation, 
or both combined, or of aortic obstruction. In some 



MODIFICATIONS OF THE HEART SOUNDS 277 

cases of great regurgitation^ with or without simulta- 
neous obstruction, the aortic sound is completely sup- 
pressed. This is not dependent on blood-pressure so 
much as on the fact that distortion of the valves 
prevents their segments from coming in contact; and 
in proportion as they leak, they avoid the sudden 
tension to which normal valves are subjected. 

How is weakening of this sound to be determined 
and measured? By comparison with the pulmonic 
sound. Now, as will presently appear, the pulmonic 
sound is often intensified when the aortic sound is 
weakened. Hence the former is not an accurate 
standard for this comparison, but it suffices for an 
approximation to accuracy. 

In cases of hypertrophy of the left ventricle, owing 
to increased arterial blood-pressure, without obstruc- 
tion, or regurgitant valvular lesions, the aortic sound 
is abnormally intensified. Intensification of the 
aortic sound may be due to increased tension in the 
systemic arteries without cardiac hypertrophy. 

A simpler cause of weakening or suppression of the 
aortic sound is damage from lesions of the aortic 
valve. In proportion as the function of this valve 
is impaired by lesions the intensity of the sound is 
diminished, and if the function of the valve be lost, 
the sound is wanting. In these cases, the pulmonic 
sound being but little or not at all affected, it is an 
accurate standard for the comparison. 

The pulmonic sound is weakened in the rare 
instances of lesions affecting the pulmonic valve. 



278 PHYSICAL CONDITIONS OF THE HEART 

This sound is oftelier intensified than weakened. It is 
notably intensified when the right ventricle is hyper- 
trophied, and especially when this hypertrophy is 
associated with dilatation of the left auricle result- 
ing from mitral obstruction or regurgitation — the 
increased sound being due to a rise of pressure in the 
pulmonary artery. 

Increased tension of the pulmonary arterial system 
may increase the intensity of the pulmonic sound, 
irrespective of hypertrophy of the right ventricle. 
This increased tension is due to whatever cause 
obstructs the pulmonary circuit, i. e., whatever puts 
obstruction in the way of the right ventricle whether 
this be obstructed or regurgitated blood at the mitral 
orifice, paralysis of the left auricle, or mechanical 
obstruction of the pulmonary veins, capillaries, or 
arteries in the lung as the result of consolidation, 
fibrosis, bronchial spasm, emphysema or defective 
expansion of the thorax. But this increased tension in 
the pulmonary artery cannot be long maintained with- 
out leading to hypertrophy of the right ventricle. The 
pulmonary second sound is also intensified in cases of 
palpitation and excitation of the heart by exercise and 
emotion. 

In comparing the aortic and the pulmonic sound 
in disease, as in health, it is to be assumed that the 
anatomical relations of the aortic and the pulmonary 
artery to the second intercostal space on either side, 
close to the sternum, are not materially altered, and 
that the lungs are free from lesions, in consequence 



MODIFICATIONS OF THE HEART SOUNDS 279 

of which the conduction of the sound on either side 
is abnormal. 

Returning to the first sounds, the mitral and the 
tricuspid sound may be studied separately. With the 
stethoscope applied at or a little to the left of the 
apex, the valvular element of the sound which is heard, 
is derived from the mitral valve, while at, or to the 
left of, the end of the sternum, the valvular element 
comes from the tricuspid. Notable weakness or 
suppression of the mitral sound, as compared with the 
tricuspid, represents impairment of the function of 
the mitral valve, and, per contra, notable weakness, 
or suppression of the tricuspid sound, denotes impair- 
ment of the function of the tricuspid valve. Allow- 
ance, in this comparison, is to be made for a normal 
disparity, the mitral sound being louder than the tricus- 
pid in health; and for a considerable normal variation. 

Reduplication of Heart .Sounds. — The sounds of the 
heart are said to be reduplicated, when either the 
first or the second sounds are repeated, or when 
both occur twice, before the long pause or interval. 
Considering the heart sounds as twofold, and as 
represented by the whispered words Lub-dup, redu- 
plication of the first sound is expressed by Lublub-dup ; 
of the second by Lub-dupdup, and of both by Lublub- 
dupdup. 

Clinically, reduplication of the second sound is 
observed much more frequently than reduplication of 
the first. In other words, the pulmonic and aortic 
sounds, instead of being synchronous, occur in sue- 



280 PHYSICAL CONDITIONS OF THE HEART 

cession. This may occur when the systolic sounds 
occur synchronously. The explanation is, that from 
increased tension of either the systemic or the pul- 
monic arteries (oftener the latter), the recoil of the 
arterial coats after the systole, and the extension 
of the sigmoid valves take place in one artery sooner 
than in the other. If both the first and the second 
sounds be reduplicated, the explanation which seems 
most rational is that the two A^entricles contract, not 
in exact unison, but that one contracts a little before 
the other. 

There is a form of functional disorder which may 
be confounded with reduplication of both sounds of 
the heart. In this disorder, with every alternate 
revolution of the heart, the sounds are weak, and 
the ventricular systole is not represented by a radial 
pulse, the force of the contraction of the ventricle 
being insufficient to cause an appreciable pulsation 
in the remote arteries; hence the heart sounds occur 
twice for each pulse at the wrist. Under these cir- 
cumstances, however, the carotid pulse may generally, 
if not always, be felt with the weak as well as with 
the stronger ventricular contraction, and in this 
way the error of confounding the disorder with redu- 
plication may be avoided. The type of arrhythmia 
here described is now known to be due to extrasystole, 
i. e., the ventricles of the heart alone participate in an 
extra contraction, which can be heard, and gives a 
palpable pulse wave or not, according to the strength 
of the contraction (vide p. 286). 



THE PULSE 281 

Reduplication of the heart sounds may occur in 
connection with cardiac lesions, or there may be no 
evidence of any organic affection. In the latter case 
the anomaly falls properly among the varied forms 
of functional disorder of the heart. Whether, or not, 
it be connected with lesions, it has no important 
pathological significance. It is usually of temporary 
duration. 

Reduplication is to be distinguished from the 
presence of a third sound, either (1) the protodiastolic 
third often heard normally in certain positions (vide 
p. 261), and of considerable va.lue in the diagnosis of 
mitral obstruction (vide p. 332); or (2) the presystolic 
third sound of auricular contraction not infrequently 
met in cases of cardiorenal disease. 

THE PULSE. 

An examination of the arterial pulse is an essential 
in every examination of a patient. We note its 
occurrence at various parts of the body, in the 
temporals, carotids, brachials, radials, femotals, 
popliteals, and in the dor'salis pedis. We observe its 
comparative qualities on the two sides of the body. 
We pay particular attention to the following char- 
acteristics: (1) Frequency (the number of beats per 
minute); (2) regularity (both as regards the size of 
individual beats and also their rhythm); (3) size 
(small or large); (4) celerity (the quickness or abrupt- 
ness with which the individual pulse waves rise and 



282 PHYSICAL CONDITIONS OF THE HEART 

fall); (5) tension (the pressure within the artery); 
and at the same time we determine (6) the character 
of the arterial wall. 

Frequency. — We note the frequency of the pulse in 
the minute, observing variations from the physio- 
logical limits, according to the age of the patient. 
An infrequent pulse may follow great bodily exer- 
tion, convalescence from severe diseases, malnutrition, 
in vomiting, during vagus stimulation, in cerebral 
compression, in jaundice, and in aortic stenosis alone 
among the valvular defects of the heart. 

If the auricles of the heart beat two, three, or 
more times as often as the ventricles (heart-block), 
we note the lack of relation by combined auscultation 
and palpation; or by observing the auricular venous 
pulse in the neck, while palpating the carotid, or 
radial artery, or the apex beat. A particularly slow 
pulse may occur during the physiological effect of 
digitalis. 

If the pulse be markedly irregular, its frequency 
may be decidedly less than the frequency of the ven- 
tricular contractions. In this case auscultation of 
the heart sounds, or palpation of the apex beat, 
should always be combined with palpation of the 
radial pulse. The difference between the ventricular 
rate and the radial pulse rate is spoken of as the 
pulse deficit. Followed from day to day, the record 
of the pulse deficit gives valuable evidence of the 
effect of treatment in improving the efficiency of 
the ventricles. 



THE PULSE 283 

A frequent pulse may be due to muscular activity, 
exhausting diseases, and debilitated states. It is 
almost always found in fever, in vagus paralysis, 
in the last stage of cerebral pressure or basilar men- 
ingitis, in neurotic and toxic states, and in exoph- 
thalmic goitre, and as an important sign of weak 
heart muscle, in almost all cardiac, valvular defects 
when compensation is failing and where there is 
vasomotor paresis, or collapse. Excessive frequency 
occurring in attacks may be observed at intervals 
for years, usually without apparent cause (paroxysmal 
tachycardia) . 

Regularity. — We note the regularity of the pulse, as 
affecting its force and frequency. 

The irregularities of the pulse are as follows : 

1. Complete loss of the dominant rhythm, the 
intervals being wholly irregular, and the beats unequal. 
This is called the completely irregular pulse, and is 
usually characterized by excessive frequency as well. 
In cases of mild degree detection clinically may be 
aided by subjecting the patient to mild exercise, as 
the irregularity is increased with the frequency. It 
indicates complete failure of the normal auricular 
contractions, the auricles being in the state called 
fibrillation. The jugular venous pulse is always sys- 
tolic in time. This type of irregularity may persist 
for years, but always denotes serious damage to 
the heart muscle. Among the valvular defects it is 
most commonly found with mitral obstruction. 



284 PHYSICAL CONDITIONS OF THE HEART 




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THE PULSE 



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286 , PHYSICAL CONDITIONS OF THE HEART 

2. Occasional interruption of a regular pulse by 
premature heart beats, usually single, rarely m 
groups. Such premature heart beats are called 
extrasy stoles. They may occur at long intervals, or 
as often as every other beat. When the latter, the 
rhythm is called bigeminy, or coupled rhythm, a con- 
dition characteristic of the early toxic eifect of 
digitalis. Extrasystoles of ventricular origin are 
characterized by a compensatory pause after the 
premature contraction — the pause being so long that 
the succeeding normal beat regains the previous 
rhythm. After auricular extrasystoles an incomplete 
compensatory pause follows, while extra contractions 
originating at the sinus have no compensatory pause 
at all. The more premature the contraction, the 
smaller the pulse wave. Very early extrasystoles fail 
entirely to open the semilunar valves. This type of 
arrhythmia is rare when the pulse rate is increased to 
100 to 120, and therefore exercise makes the rhythm 
regular in contrast to its effect in fibrillation. 
Extrasystoles are not in themselves of serious 
significance. Occasional extrasystoles are common 
toxic results of tobacco, coffee, and other poisons. 
They occur in severe fatigue, in persons with high 
blood-pressure, and without evident cause. 

3. Occasional complete omission of a heart beat, 
the true intermittent pulse. If the first heart sound 
is also absent, this indicates a temporary heart-block, 
and is seen also during the use of digitalis. If 
there is a first heart sound, but no radial pulse, it 



THE PULSE 287 

indicates an extrasystole which was not of sufficient 
force to open the aortic valve. 

4. Occasional sudden change occurs from a normal 
rhythm to a regular rhythm of usually between 160 and 
200 per minute, the rapid rhythm being maintained 
for a few beats, for hours or even days, and usually 
returning abruptly to the previous normal rate. 
This is true ^paroxysmal tachycardia. The new 
rhythm is unaffected by exertion, rest, or position. 
Abruptness of onset and of return to normal are 
particularly characteristic. 

5. Closely allied to paroxysmal tachycardia and 
but recently differentiated from it is auricular flutter. 
In this form of tachyrhythmia the electrocardiograph 
has shown that abnormal impulses are occurring in 
the auricle at between 200 and 500 per minute. The 
ventricle cannot follow such excessive rapidity, and 
a heart-block is almost invariably present. The 
most common finding is an auricular rate of 320 per 
minute with heart-block of 2 to 1, so that the ven- 
tricular rate (and arterial pulse) is 160. The change 
from normal rhythm to auricular flutter is not abrupt, 
as in paroxysmal tachycardia, but is separated by 
a period • of auricular fibrillation. " If tachycardia 
persists for a month or more and is not changed in 
rate by change of posture, rest or exercise, the case 
is almost surely one of flutter." (Mackenzie.) 

6. Moderate variation in the rate of the dominant 
rhj^hm, synchronous with respiration, is normal in 
children and in many adults. This is called the 



288 PHYSICAL CONDITIONS OF THE HEART 

respiratory irregularity, or sinus arrhythmia, as it 
depends upon the varying rate of discharge of 
impulses from the sinus node, the normal pace-maker 
of the heart. Similar variation in the dominant 
rhythm occurs in excitement, and may be marked in 
meningitis. It is due to stimuli received by the 
heart through the vagus nerves, and never signifies 
disease of the heart muscle. Exertion decreases or 
stops the irregularity. 

7. Alternation of large and small beats, without 
noticeable variation in the intervals which separate 
them, constitutes the alternating pulse. It is to be 
carefully distinguished from bigeminy, that variety 
of extrasystolic arrhythmia in which every second 
beat is premature. In both conditions small and 
large beats alternate, but in pulsus bigeminus the 
small beat comes in ahead of its proper time and is 
followed by a compensatory pause. In pulsus alter- 
nans irregularity of size alone occurs. The prog- 
nosis is much more grave, for the condition is due to 
serious impairment of the contractile power of the 
heart muscle. 

Inspiration may cause decrease in the size even to 
obliteration, and frequency of the pulse, in cases of 
inflammations and tumors of the mediastinum 
(pulsus paradoxus). 

Size. — The pulse is large or small, according to 
relation between the amount of blood delivered to 
the great vessels during systole, and the emptiness 
of the vessels at the end of diastole. We find a large 



THE PULSE 289 

pulse often in hypertrophy of the left ventricles, 
expecially in aortic regurgitation, and often in the 
sthenic stage of fevers. We find the pulse small 
in syncopal attacks, in cardiac muscular weakness, 
• in stenosis of any cardiac valvular orifice, particularly 
in mitral and aortic stenosis, and during chills. 

Inequality of size and force upon the two sides is 
sometimes present as a result of abnormalities of the 
size of the arteries upon one side, or from pressure 
as by an aneurism of the aorta. 

Quickness. — We note the rapidity with which the 
pulse fills and empties (or the celerity). We find a 
quick pulse in the collapsible pulse of aortic insuffi- 
ciency (the water-hammer or Corrigan pulse), and 
where we have a relaxed arterial wall at the same 
time that the heart is overacting, as in the asthenic 
stage of fevers. We have a slow pulse in aortic 
stenosis, and where we have high peripheral resis- 
tance and no disturbance of the reflex nervous control 
of the heart. 

Tension. — We note the sense of resistance or tension 
of the pulse as appreciated by applying the tips of 
three fingers to the artery, and noting the pressure 
needed at the proximal finger to prevent the appre- 
ciation of the pulse by the distal finger. Although 
we may get a general impression of the tension by 
palpation, very great errors are so frequently made 
that palpation estimations of blood-pressure are 
today unjustifiable as a basis for diagnosis or treat- 
ment. 
19 



290 PHYSICAL CONDITIONS OF THE HEART 

A hard pulse is with difficulty obliterated by digital 
pressure. Nephritis of the chronic type and advanced 
arteriosclerosis usually exhibit a hard pulse. 

A soft or easily compressible pulse is found in fever, 
anemia, weakness of the heart muscle, and in vaso- 
motor paresis. 

Character of Arterial Wall. — ^We note the character 
of the arterial wall, i. e., whether the arterial wall 
is palpable or not, when the pulse is obliterated by 
pressure farther up the arm. The normal radial artery 
is not palpable when empty. A firmly contracted 
artery is to be distinguished from an artery with an 
hypertrophy of its muscular wall, and both of these 
conditions from a smooth fibrous replacement in the 
wall, or, what is easier, from the so-called pipe-stem 
artery with nodular calcareous deposits. These are 
appreciated by rolling the vessel under the finger-tips, 
or the edge of the nails. 

Capillary Pulsation. — The capillaries may show sys- 
tolic pulsation in cases where the arterial pulse is very 
large. It is therefore seen particularly in aortic insuffi- 
ciency, though also in some cases of low blood-pressure 
from decreased tone in the end arteries, as in exophthal- 
mic goitre or neurasthenia. The capillary pulse may 
be seen as a faint pulsation if a microscope slide be 
pressed against the mucocutaneous margin of the lower 
lip, just hard enough to blanch the skin, or if the end of 
the nail is bent, to the point of blanching the pulp 
beneath, or in the systolic flushing of a line drawn 
across the forehead by the finger. 



THE PULSE 291 

Pulsation of the Cervical Veins. — ^A pulsation in the 
external jugular veins for about three-quarters to 
an inch above the clavicle is normally visible in the 
majority of people when lying down. It depends upon 
the pressure changes in the right auricle, the pulsation 
being transmitted up the column of blood within the 
veins and through the intervening valves. In the 
erect posture gravity and the normal negative pressure 
within the thorax keep these veins so empty that 
transmission of such weak pulsations is usually impos- 
sible. On the other hand, if the veins be constantly 
distended, the pulsation is too weak to cause appreciable 
increase in their size, and no pulsation is seen, as can 
be demonstrated by tilting the patient's head suffi- 
ciently downward. In cases of emphysema, therefore, 
where the negative pressure of the thorax is much 
decreased, venous distention may obliterate the normal 
pulsation when horizontal, although it is present in 
the upright position, especially when the intrathoracic 
negative pressure is increased during inspiration. 

The pulsation in the veins is visible, but very rarely 
appreciable by the touch. It is to be distinguished from 
pulsation of the arteries of the neck. This is easily 
done by finding that pressure just above the clavicle, 
sufficient to interrupt the flow of blood in the veins 
but not in the arteries, abolishes the pulsation. Careful 
inspection shows the venous pulsation to be, not a single 
wave, but a flickering which may be resolved into 
three component waves, named A, C, and V respectively. 
The wave A corresponds to the contraction of the right 



292 PHYSICAL CONDITIONS OF THE HEART 

auricle, C to the closure of the tricuspid valves, and 
^^ to filling up of the right auricle during ventricular 
systole (vide Fig. 19, p. 284). 

The most significant feature of the venous pulse is its 
change in character in tricuspid insufficiency. When this 
occurs the right auricle receives blood both from the 
veins and also from the right ventricle during ventricular 
systole. As a result the V wave increases in size and 
begins earlier, even to a point where it completely 
obliterates the C and the A waves. In marked tricuspid 
regurgitation, "instead of the usual A-C-V fiicker, 
we find a large, slow, heaving pulsation synchronous 
with the carotid {vide Fig. 19, p. 284). 

CARDIAC MURMURS. 

All adventitious abnormal sounds which are added 
to the heart sounds are embraced by the term cardiac 
murmurs. Let it be borne in mind that the murmurs 
are never abnormal modifications of the heart sounds, 
but always new^ly produced sounds, and they always 
represent morbid conditions of either the heart or the 
blood. When due to morbid conditions of the blood 
they are called inorganic, anemic, or hemic murmurs, 
and w^hen they represent valvular lesions or changes 
within the heart they are distinguished as organic 
murmurs. 

In fevers, as of the acute infectious diseases, or in 
high temperature from various other causes, we com- 
monly find a systolic murmur at the apex correspond- 



CARDIAC MURMURS 293 

ing to the murmur of mitral regurgitation. This may 
be heard also in marked anemia and in extreme asthenia, 
and this murmur may properly be called a functional 
murmur, as it seems to be due to an atonic or relaxed 
condition of the mitral ring, and to a lack of proper 
functioning of the papillary muscles. 

A systolic murmur heard over the base of the heart, 
especially at the second left interspace, seems to be 
due to a dilatation of the conns arteriosus, and is found 
to occur not infrequently in fever and anemias, and 
from unexplained causes. 

In healthy adults there is, not uncommonly, during 
expiration, a systolic murmur heard over the base of 
the heart, and disappearing during inspiration. This 
is usually more easily heard in those with flat chests. 
It is rather common in children. * The important dis- 
tinguishing point about this murmur is its dependence 
upon the expiratory phase of respiration. Its causation 
is not well understood. 

There are other accidental murmurs, usually systolic, 
but occurring also in any part of the cardiac cycle, 
of which the cause is uncertain and the importance 
negligible. 

The rnurmurs may be distributed into three groups 
after differences in quality, namely: (1) soft; (2) rough; 
and (3) musical murmurs. The soft murmurs resemble 
the sound produced by air from the nozzle of a pair 
of bellows, and, hence, are often called bellows mur- 
murs. Murmurs are said to be rough when their 
qualities may be expressed by such terms as rasping, 



294 PHYSICAL CONDITIONS OF THE HEART 

rumbling, croaking, etc. They are called musical 
when the sound is a musical note. The bellows murmurs 
are the most frequent, and the musical are more rare 
than the rough murmurs. The quality of a murmur has 
not in general any special pathological or diagnostic 
significance. The murmurs vary in pitch, being either 
relatively high or low. The variations in pitch are useful 
in aiding to discriminate different coexisting murmurs. 

This account of murmurs applies to those produced 
at the orifices or within the cavities of the heart. 
They are distinguished as endocardial murmurs. 
Adventitious sounds are, however, produced upon 
the external surface of the heart. These constitute 
pericardial, or friction murmurs. 

Endocardial murmurs are produced by blood- 
currents pursuing either a normal or an abnormal 
direction. With a familiar knowledge of these cur- 
rents, and of their relations with the heart sounds, 
the several endocardial murmurs are very easily 
understood. 

Directing the attention to the left side of the heart, 
there are two normal blood currents — namely, the cur- 
rent from the left auricle to the left ventricle, and the 
current from the left ventricle into the aorta. These 
may be distinguished as the direct currents. The first 
is the mitral direct current, and the second is the aortic 
direct current. 

Two abnormal currents may occur in the left side of 
the heart. These currents can only take place when 
the valves are rendered incompetent by lesions. The 



i__ 



CARDIAC MURMURS 295 

incompetency of the valves allows of regurgitation, 
and these abnormal currents may be distinguished as 
the regurgitant currents. One of these is a current 
backward from the left ventricle into the left auricle, 
owing to incompetency of the mitral valve; this is 
the mitral regurgitant current. The other is a current 
backward from the aorta into thfe left ventricle, arising 
from incompetency of the aortic valve; this is the 
aortic regurgitant current. 

What are the relations of the four currents in the 
left side of the heart with the heart sounds. The 
mitral direct current takes place when the mitral valve 
opens after ventricular systole, and continues open 
up to the closure of the valve at the following systole. 
In other words, blood flows through the mitral valve 
throughout ventricular diastole — that is, from the time 
of the second sound up to the following first sound — 
and murmurs due to obstruction of the mitral valw can 
only occur at some period of ventricular diastole. This 
period covers the time of rest of the whole heart 
(diastole), and also the period of auricular contraction 
(spoken of clinically as presystole). 

The mitral regurgitant current is caused by the con- 
traction of the ventricle; the current, therefore, must 
take place during ventricular systole, that is, beginning 
with the first sound and lasting practically up to the 
second. 

The aortic direct current, being caused by the contrac- 
tion of the left ventricle, takes place during systole. 
It is therefore coincident with the mitral regurgitant 
current. 



296 PHYSICAL CONDITIONS OF THE HEART 




Fig. 20. — Diagram representing the normal blood currents. 
Plain arrows represent currents in right side of heart. Dotted 
arrows represent currents in left side of heart. 




Fig. 21. — Diagram representing the abnormal blood currents. 
Plain arrows represent currents in right side of heart. Dotted 
arrows represent currents in left side of heart. 




Carotid pulse. 







Apex impulse, showing a small wave due to auricular contraction 
preceding the ventricular. 



■ 



Normal heart sounds; and (in dotted Unes) the points at which 
presystolic and protodiastolic third sounds may be heard. 



ftj 



Systohc murmur as in insufficiency of auricular ventricular valves 
or stenosis of semilunar valves. 



Diastohc diminuendo murmur of aortic insufficiency. 



Mitral stenosis with short intense Si (snapping first sound) 
and presystoHc crescendo rumble (moderate narrowing with 
a strong auricle). 




Mitral stenosis, severe grade; rumble throughout diastole with 
presystoHc accentuation. 






Mitral stenosis with auricular fibrillation, diastolic murmur, no 

presj^stolic. 



I 



1^ 



Mitral stenosis with distinct protodiastolic third sound with 
which an early diastolic rumble starts. 
Fig. 22. — Diagram of time relations of auricular and ventric- 
ular systole (shown on apex impulse) to carotid pulse, heart 
sounds, and murmurs. 



298 PHYSICAL CONDITIONS OF THE HEART 

The aortic regurgitant current is caused by the recoil 
of the arterial coats upon the column of blood within 
the aorta, directly after the ventricular systole; and as 
this recoil causes the aortic second sound of the heart, 
the current and this sound must start together, unless 
the second aortic sound is wholly replaced by the sound 
of the regurgitant current. The leakage backward 
through an incompetant aortic valve begins with the 
second sound and continues up to the following ven- 
tricular systole. 

Recapitulating the relations of the four currents 
with the heart sounds, the aortic direct and the mitral 
regurgitant are systolic currents. The mitral direct 
current and the aortic regurgitant current takes place 
during ventricular diastole. 

Analogous blood currents take place in the right 
side of the heart, and have corresponding relations 
with the heart sounds. These currents are the tri- 
cuspid direct, the tricuspid regurgitant, the pulmonic 
direct, and the pulmonic regurgitant. The pulmonic 
regurgitant is rare in consequence of the infrequency 
of pulmonic lesions; but the tricuspid regurgitant is not 
uncommon, and occurs without valvular lesions or 
enlargement of the heart when the right ventricle is 
distended with blood, constituting what has been 
called the ''safety valve function" of the tricuspid 
orifice. 

Organic endocardial murmurs are produced by 
the foregoing direct and regurgitant blood currents, 
and they are designated by the same names, that is, 



CARDIAC MURMURS 299 

they are either direct or regurgitant murmurs. Thus 
there are produced in the left side of the heart — the 
side in which valvular lesions are seated in the great 
majority of cases — a mitral direct murmur, a mitral 
regurgitant murmur, an aortic direct murmur, and 
an aortic regurgitant murmur. In the right side of 
the heart there may be produced corresponding mur- 
murs — namely, a tricuspid direct, a tricuspid regurgi- 
tant, a pulmonic direct, and a pulmonic regurgitant. 

Mitral Direct Murmur. — This murmur is due to vibra- 
tions of the mitral direct current flowing through the 
mitral valve. Vibrations of moderate degree are nor- 
mally present and can be heard, as Thayer has shown, 
with a stethoscope applied directly to the left ventricle. 
They are not normally, except in rare instances, of 
sufficient intensity to reach the chest wall. Narrowing 
of the valve (mitral stenosis) increases the velocity 
of flow and therefore the vibrations, which then 
become audible at the chest wall. 

With a severely obstructed mitral valve and a strong 
right heart, the velocity of flow may be sufficiently 
maintained to produce a murmur throughout the whole 
period of ventricular relaxation. The murmur then 
begins with the second sound and continues to the 
following first sound, filling the period of rest of the 
whole heart and also that of auricular systole (pre- 
systole). It is sometimes called diastolic-presystolic 
in time. 

Such murmurs, though not infrequent, are less 
common than those heard only in a portion of the period 



300 PHYSICAL CONDITIONS OF THE HEART 

of ventricular diastole. The velocity of flow through 
an obstructed mitral valve is greatest when the pressure 
in the auricle is highest, in comparison to that in the 
ventricle. If the auricle were paralyzed, obviously 
it would be most distended just at the end of ven- 
tricular systole, for during that period blood has been 
steadily pouring into the auricle from the pulmonary 
veins. In such a case we would expect the velocity of 
flow, and consequently the murmur, if present, to be 
most marked at the beginning of ventricular relaxation 
and to decrease as the ventricle became filled; and this 
we find to be the case in just those cases where the auricle 
has ceased its coordinate contractions {auricular fibril- 
lation), provided the right heart continues to maintain 
a reasonable pressure in the pulmonic vessels. The 
murmur occurs in early and mid-diastole. 

Where the left auricle is not paralyzed, however, 
its contraction accelerates the flow of blood at each 
auricular systole, intensifying the vibrations at that 
period; so that the murmur is particularly audible at 
this (presystolic) time. On the other hand, a strong 
left auricle that has emptied itself in systole, has 
room in diastole to accommodate the inflow from the 
pulmonary veins without being subjected to great 
distention. Ventricular diastole, therefore, finds the 
blood within the auricle under less pressure than in the 
case of the paralyzed auricle, so that there is less cause 
for a murmur in early diastole. In the cases of moderate 
and well-compensated mitral stenosis, therefore, the 
murmurs are most frequently present at the time of auric- 
ular systole — that is, they are usually presystolic. 



CARDIAC MURMURS 301 

Almost invariably this murmur is rough in quality; 
occasionally it is a soft bellows murmur. When rough 
it is often quite loud. The rough quality is peculiar; 
it is suggestive of vibration, and may be imitated by 
causing the lips or the tongue to vibrate with the breath 
in expiration. It is caused by the vibrations of the 
mitral curtains, and takes place when these curtains 
are united at their sides, leaving a narrow buttonhole- 
like orifice through which the mitral direct current of 
blood flows. Throwing the lips into vibration with the 
breath, represents not only the characteristic quality 
of the murmur, but the mode of its production. The 
physical conditions which ar^e requisite generally for 
its production are a narrowed mitral orifice, and 
enough pressure within the auricle to force the blood 
through the obstruction at sufficient velocity. The 
latter condition is not always present so that a murmur, 
previously 'plain, may disappear tvith the onset of severe 
decompensation. * 

This murmur may be produced artificially, and the 
mechanism of its production demonstrated in the fol- 
lowing manner: Take a small India-rubber bag with 
thin walls — such as that which, when infiated, makes a 
balloon for children; attach the opening to the efferent 
tube of a Davidson swinge; make a small orifice 
opposite to the attached opening of the bag; immerse 
the bag in a basin of water, and then force a current 
of water into the bag. With a binaural stethoscope, 
the pectoral extremity applied lightly to the bag, a 
murmur caused bv the flow of water from the bag into 



302 PHYSICAL CONDITIONS OF THE HEART 

the basin is heard, resembling as closely as possible the 
usual presystolic murmur. 

A mitral direct murmur is never due to a morbid 
condition of the blood. Although it occurs without 
mitral lesions {vide Flint murmur, p. 303), yet, inasmuch 
as its occurrence then requires the existence of aortic 
regurgitant lesions, it cannot be said to be an inorganic 
murmur. A mitral direct murmur may occur in 
adherent pericardium (chronic fibrous pericarditis), 
and in large hearts without valvular lesions; in the 
latter the accessory signs of mitral stenosis are lacking. 

A mitral direct murmur, as has been stated, does 
not always accompany mitral lesions. If the mitral 
curtains are fixed or made rigid by calcification, so 
that vibration with the mitral direct current of blood 
does not take place, either the murmur may be wanting, 
or its usual characteristic quality may be absent. 
Feebleness of the auricular contraction, from dilatation 
or overdistention of the auricle with blood, may cause the 
murmur to disappear from presystole. Under these cir- 
cumstances the murmur may be sometimes present and 
at other times absent. Cardiac vibration or thrill is a 
physical sign which accompanies often a well-marked 
characteristic presystolic murmur, but this sign may 
occur in connection with other valvular lesions. The 
thrill is presystolic or diastolic-presystolic in time. 

It is apparent, then, that in mitral stenosis, owing 
to the differences in the size of the opening, the flexi- 
bility of the cusps, the volume of blood and the force 
of the auricular contraction, we may have an absence 



CARDIAC MURMURS 303 

of any murmur, or most commonly a presystolic 
murmur, or less often a murmur which may occupy 
any point of time between the systolic sound and the 
diastolic sound of the heart, i. e., a diastolic, or meso- 
diastolic, or diastolic-presystolic murmur. 

The Flint Murmur. — ^A mitral direct murmur may be 
produced without mitral lesions, the murmur having 
the same characteristic quality as when lesions exist, 
and being also quite loud. This fact, based on clinical 
proof, was stated by me many years since, together 
with the explanation. The murmur occurs when there 
are aortic lesions which permit regurgitation. Under 
these circumstances, at the time when the auricular 
contraction takes place, the left ventricle is already 
filled with blood, the mitral curtains are floated out 
so as to be in contact with each other, the anterior 
curtain being also pushed shut by the stream of regur- 
gitating aortic blood which strikes its anterior surface 
{vide Fig. 23, p. 304). The mitral direct current pass- 
ing between the curtains throws them into vibration 
precisely as when the orifice is narrowed. The vibra- 
tion of the lips when lightly in contact, caused by the 
expired breath, illustrates the manner in which a mitral 
direct murmur takes place without mitral lesions. The 
murmur thus occurring without mitral lesions is more 
variable from day to day than is the murmur of mitral 
stenosis; it is now present and now absent. It follows 
from what has just been stated that a mitral direct 
murmur is not always a sign of mitral obstructive 
lesions when there is free aortic regurgitation. (This 



304 PHYSICAL CONDITIONS OF THE HEART 

murmur is commonly recognized in the United States 
as the FHnt murmur.) 




Fig. 23. — Frontal section of the thorax, showing ascending and 
descending vena cava; left ventricle and the close relation of aortic 
valve to the anterior curtain of the mitral valve. From this 
specimen the rc-ray, Fig. 16, p. 258, was taken. (Norris and 
Fetterolf.) 



CARDIAC MURMURS 305 

This murmur is limited to a circumscribed space 
around the apex of the heart. However loud the mur- 
mur may be in this situation, it is usually lost within 
a short distance of the apex, although in rare instances 
it may be heard over the lower part of the left scapula.^ 

Mitral Regurgitant Murmur — Mitral Systolic Murmurs 
of Cardiorespiratory and Functional Origin. — The mitral 
regurgitant murmur, synchronous with and follow- 
ing the systolic sounds, that is, a systolic murmur may 
be soft, rough, or musical in quality, its intensity and 
pitch being variable. Aside from its relation with the 
first or systolic heart sounds, it is distinguished by 
having its maximum of intensity at or near the situa- 
tion of the apex beat. It may be limited to a circum- 
scribed area, and if heard at a distance from the apex 
it is best transmitted laterally round the left side of 
the chest, on the line of the apex. This is of particular 
significance in diagnosis because the systolic murmurs 
originating at other valves may sometimes be heard 
even as far as the apex, but practically never beyond it. 
It is often heard on the posterior aspect of the chest 
near the lower angle of the left scapula, and not infre- 
quently in the corresponding situation on the right 
side. 

The impulse of the apex of the heart against the 
adjacent portion of the lung sometimes forces the air 
from the air vesicles sufficiently to give rise to a blow- 

^ For further diagnostic and explanatory details of the Flint 
murmur the reader is referred to an article by Thayer in Amer. 
Jour. Med. Sci., 1901, cxxii, No. 6. 
20 



306 PHYSICAL CONDITIONS OF THE HEART 

ing sound occurring with each ventricular systole. This 
is liable to be confounded with an endocardial murmur. 
Produced in the way just stated, it is heard only during 





Fig. 24. — Showing at X apex beat where the murmurs of 
mitral regurgitation and mitral obstruction can be best heard. 
The arrow pointing outward indicates the direction in which the 
regurgitant murmur is transmitted, and the arrow pointing to 
the sternum shows the area in which murmurs of mitral stenosis 
may occasionally be transmitted. (Hare.) 



the act of inspiration, and especially at the end of this 

act. Such murmurs are known as cardiorespiratory. 

A purely functional incompetency of the mitral valve 

occurs, permitting a mitral regurgitant current, no 



CARDIAC MURMURS 307 

actual lesion of the valve or the mitral orifice existing. 
This functional regurgitation depends upon decreased 
tone of the muscular fibers of the mitral ring allowing 
dilatation of the opening, and upon impaired action 
of the papillary muscles. In this way are explained the 
occurrence of a mitral systolic murmur and its dis- 
appearance without other evidence of endocarditis or 
any organic affection of the heart. 

That a mitral systolic murmur may exist, continue 
for weeks or months, and even for years, and disappear, 
the murmur being neither accompanied nor followed 
by signs or symptoms denoting organic disease, is an 
important fact to be borne in mind with reference to 
diagnosis and prognosis. It is apparent from experi- 
mental studies as well as from clinical observation that 
a true mitral regurgitation, with the characteristic 
murmur so constantly associated when the valve cusps 
are diseased, may occur from any of several causes 
which permit of a relaxation of the constrictor ring of 
muscle which encircles the mitral orifice. Among the 
causes frequently recognized are high temperature, 
acute endocarditis, with or without coexisting chorea, 
and any cause, either general (anemia) or local (myo- 
carditis), which may interfere with the muscular com- 
petence of the mitral ring. Strain of the heart muscle 
is apt to be a determining factor. Mitral incompetence 
from such lack of muscular efficiency is much more 
commonly accompanied by tricuspid incompetence 
than when the mitral leak is due to disease of the 
cusps themselves. 



308 PHYSICAL CONDITIONS OF THE HEART 

Aortic Direct Murmur. — ^This murmur, like the mitral 
systolic murmur, occurs with and following the systolic 
sound of the heart. Of the organic murmurs on the 
left side of the heart, the mitral systolic murmur and 




Fig. 25. — Showing the area of greatest intensity and the 
direction of transmission into subclavian and carotid arteries 
of the aortic obstructive murmur. (Hare.) 



the aortic direct murmur are synchronous, the others 
having different relations with the heart sounds. 
The aortic direct murmur differs from the mitral 
systolic murmur in having its maximum of intensity 
at the base of the heart. It is loudest in the second 



CARDIAC MURMURS 309 

intercostal space near the sternum. As a rule it is 
louder in this intercostal space on the right than on 
the left side; this rule, however, has frequent excep- 
tions. It is transmitted better and farther upward 
than downward. It is always heard over the carotid 
artery, and it is sometimes louder over this artery 
than at the base of the heart. As a murmur may be 
produced within the carotid artery, it is desirable to 
determine, when a systolic murmur is heard at the 
base, whether the carotid murmur is a transmitted 
murmur or not. This point is to be settled by com- 
paring the murmur over the carotid with the murmur 
at the base, as regards quality and pitch. If the 
quality and pitch of the murmur in the two situations 
be the same, it is fair to consider the murmur in the 
carotid as not produced within the artery, but con- 
ducted by the blood current from the aortic orifice. 
An aortic direct murmur is frequently inorganic. 
It is to be considered as such when it is not associated 
with an aortic regurgitant murmur, cardiac enlargement 
or evidence of previous syphilitic infection; and when 
anemia is shown by the presence of murmurs in the large 
arteries, and the venous hum^ in the neck — these 



1 To obtain the venous hum {}>ruit de diable), cause the patient 
to turn the head as far as practicable to the left, and apply the 
stethoscope to the neck on the right side, near the clavicle, behind 
the sternocleidomastoid muscle. Press the stethoscope with 
different degrees of force before concluding that the murmur is 
wanting. The venous hum is continuous, and closely resembles 
the sound of the humming top. Gentle pressure, with the finger 



310 PHYSICAL CONDITIONS OF THE HEART 

physical evidences of anemia being associated generally, 
not invariably, with pallor, and with symptoms point- 
ing to impoverishment of the blood. Moreover, an 
inorganic murmur is very rarely rough, and it is vari- 
,able in its occurrence, being at one time present and 
at another time absent, whereas, an organic murmur 
is, in general, constant. Associated with other evi- 
dence of anemia, an aortic direct murmur may, never- 
theless, be organic; but, under the differentiating 
circumstances just stated, the lesion represented by 
the murmur, if the murmur be organic, must be 
innocuous, so that it is not of great practical impor- 
tance to determine whether the murmur be or be not 
inorganic. 

Like the other organic murmurs, an aortic direct 
murmur varies in different cases in intensity, quality, 
and pitch. An organic aortic direct murmur per se 
does not by any means always denote aortic obstruc- 
tion {vide p. 333). It may be due simply to roughness 
of the membrane at or above the aortic orifice, or to 
dilatation of the aorta. Such evidence as these, whether 
attributed to roughness or to dilatation, are recognized 

above the stethoscope, so as to interrupt the flow of blood in 
the veins, causes the murmur at once to cease. This fact is 
proof of its being a venous murmur. A systolic murmur heard 
with the stethoscope applied to the neck is an arterial murmur 
which may either be produced within the artery or transmitted 
from the aortic orifice. An arterial and a venous murmur in the 
neck often coexist. One cause of error in determining the 
presence of a true venous hum is the common occurrence of a 
murmur in the vessels of the thyroid gland. 



CARDIAC MURMURS 



311 



as proof of inflammation of the aorta, almost without 
exception of syphilitic origin. 

Aortic Regurgitant Murmur — Aortic Diastolic Non- 
regurgitant Murmur, or a Prediastolic Murmur. — ^An 
aortic regurgitant murmur occurs with, and following, 





Fig. 26. — Showing the area in which the murmur of aortic 
regurgitation can be most clearly heard, ,jThe left nipple is raised 
by the position of the arm. (Hare.) 



the second sound of the heart. It is almost always 
heard at the base of the heart, but, in some instances, 
when not appreciable at the base, it is heard a little 
below the base — namely, near the sternum on the 
left side on a level with the fourth costal cartilage. In 



312 PHYSICAL CONDITIONS OF THE HEART 

some instances, however, the maximum of intensity 
is in a corresponding situation on the right side. 
It is transmitted best in a downward direction, being 
often heard at the apex, and sometimes considerably 
outside or external to this point (i, e., in the left 
axilla). It is never inorganic. It is usually not 
intense, low in pitch, and soft; but it may be loud, 
high, rough, or musical. 

The aortic diastolic murmur is sometimes heard 
with the ear when it is inaudible with the usual small- 
bell stethoscope. 

A short murmur is sometimes produced by the 
retrograde movement of the blood current within 
the aorta, the aortic valve being intact, and regurgi- 
tation, therefore, not taking place. .This murmur is 
due to roughening of the lining membrane of the 
aorta by atheroma or calcareous deposit, and it is 
always preceded by an aortic direct murmur. It 
occurs directly after the systole, and ends with the 
second sound. Although of such brief duration, it 
is distinctly recognizable and distinguished from the 
preceding aortic direct murmur. I have long been 
accustomed to demonstrate this murmur in private 
teaching, and have called it an aortic diastolic non- 
regurgitant murmur. A better name is a predias- 
tolic murmur. It cannot be said to have much prac- 
tical importance, inasmuch as the lesion giving rise 
to it is represented by the aortic direct murmur which 
precedes it. This murmur may be associated with a 
true regurgitant murmur. This is the explanation 



CARDIAC MURMURS 313 

of a diastolic murmur which is rough before and soft 
after the aortic second sound. 

Coexisting Endocardial Murmurs.— The murmurs refer- 
able to the left side of the heart, which have been 
considered, are often found in combination; two or 
three may coexist, or all of them may be present. 
Moreover, with more or less of these murmurs may 
be associated murmurs referable to the right side of 
the heart. The mitral murmurs are not infrequently 
associated. The mitral direct, being diastolic, ends 
with the systolic sounds, and the mitral systolic or 
regurgitant begins with these sounds; the systolic 
sounds, as it were, divide these two murmurs. These 
murmurs almost invariably differ from each other in 
pitch and quality. The presence of both, in fact, 
assists, rather than obstructs, the recognition of each. 
The aortic direct and the aortic regurgitant murmur, 
also, are often associated. A murmur then accompanies 
the systole and diastole of the heart; the two murmurs 
follow in the same rhythmical order as the groups of 
heart sounds. These murmurs, when associated, can 
only be confounded with pericardial friction sounds. 

The combination of the aortic direct and the mitral 
systolic murmur alone offers any difficulty. These 
two murmurs have the same relation with the heart 
sounds; they are both systolic. How is it to be deter- 
mined, when a systolic murmur is heard both at the 
base and apex, whether a mitral murmur is trans- 
mitted to the base, or an aortic murmur is transmitted 
to the apex; in other words, whether two murmurs are 



314 PHYSICAL CONDITIONS OF THE HEART 

present or only one murmur? If these two murmurs 
coexist, generally the circumstances which distinguish 
each separately can be ascertained. Thus, the aortic 
murmur is transmitted into the carotid artery, and the 
presence of that murmur is then established; the mitral 
regurgitant murmur is often transmitted laterally 
around the chest, or heard at the lower angle of the 
scapula, and then the presence of that murmur is 
established. But there are additional points, namely, 
the murmur at the base and that at the apex generally 
differ sufficiently in pitch or quality to render it evident 
that there are two murmurs; and generally at a situa- 
tion in the precordia between the base and apex both 
murmurs may be either lost or become notably 
weakened. Attention to these points in most instances 
divests the problem of difficulty. 

Mitral and aortic lesions are often of a character 
to give rise to only one murmur at either of these 
orifices. A mitral direct murmur is occasionally 
present without the mitral regurgitant, and the reverse 
of this is often found. So, either an aortic direct or 
an aortic regurgitant murmur may exist without the 
other. 

Tricuspid Direct Murmur. — ^The lesions which are 
requisite for this murmur very rarely occur at the 
tricuspid orifice; hence this murmur is exceedingly 
rare. It is to be distinguished from the mitral direct 
murmur by its localization, being, not at the apex, 
but at the right border of the heart. Mitral direct 
murmur is usually found to coexist with a tricuspid 



CARDIAC MURMURS 315 

direct murmur, in which case a presystoHc murmur, 
with the characteristic blubbering quahty is heard at 
the apex and at the right side of the heart. 

Tricuspid Regurgitant Murmur. — ^This murmur is not 
of infrequent occurrence. Tricuspid regurgitation 
occurs often when the right ventricle is considerably 
dilated, without the existence of lesions of the valve. 
Tricuspid regurgitation, however, does not invariably 
give rise to an appreciable murmur. When a ven- 
tricular venous pulse is found in the neck, or better 
still, if a systolic liver pulse is found, these help 
materially to establish a diagnosis of tricuspid regur- 
gitation when taken with the other signs. 

The tricuspid regurgitant murmur, of course, occurs 
with the first or systolic sound, being systolic like 
the mitral regurgitant murmur; and the latter generally 
coexists. It is distinguished from the mitral regur- 
gitant by its localization at the right inferior margin 
of the heart, and its transmission to the right, rather 
than to the left. The coexistence of the mitral and 
the tricuspid regurgitant murmurs is determined by 
the differences in pitch and quality between a systolic 
murmur at the apex and at the right margin of the 
heart. A venous pulse, synchronous with the first 
sound of the heart, and a systolic pulsation of the liver 
are far better signs of tricuspid insufficiency than is 
the presence or absence of a systolic murmur at the 
tricuspid area. 

Pulmonic Direct Murmur. — ^A pulmonic direct mur- 
mur, if organic, is generally connected with con- 



JjM 



316 PHYSICAL CONDITIONS OF THE HEART 

genital lesions. The pulmonic direct and the aortic 
direct current of blood taking place at the same 
instant, the murmurs representing both are systolic. 
How is the pulmonic to be distinguished from the aortic 
direct murmur? The pulmonic murmur is heard in 
the left second intercostal space close to the sternum, 
but this is not very distinctive, inasmuch as, not 
infrequently, the aortic murmur is loudest in that 
situation. The essential point of distinction is this: 
the pulmonic direct murmur is not transmitted into 
the carotid artery, whereas the aortic direct murmur 
is always thus transmitted. A systolic thrill, appre- 
ciated by firm palpation in the second left interspace, 
is an important and fairly constant sign in pulmonary 
stenosis. If an aortic direct and a pulmonic direct 
murmur coexist, the combination is to be ascertained 
by finding that the murmur in the second intercostal 
space on the right side differs from that on the left side 
in pitch or quality. 

An inorganic or functional pulmonic direct murmur 
is of frequent occurrence in cases of anemia. It is 
frequently associated with an inorganic aortic direct 
murmur, the presence of the two mm-murs being evi- 
denced by a difference in pitch. 

Pulmonic Regurgitant Murmur. — ^This murmur is 
exceedingly rare in consequence of the infrequency 
of pulmonic regurgitant lesions. It occurs, of course, 
like the aortic regurgitant, with the second or diastolic 
sound. Its presence can be determined when other 
signs go to show the existence of pulmonic and the 



CARDIAC MURMURS 317 

absence of aortic lesions. This murmur may, however, 
occur without any lesion or deformity of the pulmonary 
valve cusps or of its orifice under conditions similar 
to those which may determine an aortic regurgitant 
murmur — namely, increased blood-pressure in the pul- 
monary artery, due to marked obstruction in the 
pulmonary vessels, sufficient to cause a dilatation of 
the pulmonary orifice, and lack of apposition of the 
semilunar cusps. This so-called murmur of high press- 
ure in the pulmonary artery is commonly known as 
the Graham-Steell murmur. A pulmonic regurgitant 
murmur may occur from pressure upon the pulmonary 
artery from without. 

Facts of practical importance in relation to the 
endocardial murmurs are embraced in the following 
statements : 

The question as to a murmur being organic or inor- 
ganic relates chiefly, if nor entirely, to the aortic direct, 
the pulmonic direct, and the mitral regurgitant murmur, 
other murmurs being almost invariably organic. 

Associated signs and symptoms {vide Valvular 
Lesions) generally warrant a definite conclusion whether 
an aortic direct or pulmonic direct murmur be, or be 
not, organic, and under the circumstances which render 
it difficult to decide this question positively, a positive 
decision is not of much immediate practical conse- 
quence. 

Valvular lesions, whether obstructive, regurgitant,, 
or innocuous, are so uniformly represented by murmur, 
in a compensating heart that, as a rule, absence of 



318 PHYSICAL CONDITIONS OF THE HEART 

lesions may be predicated on the absence of murmur. 
If, however, the signs and symptoms of "a decompen- 
sating heart are present, no conclusions should be 
drawn from the presence or absence of murmurs as 
to the existence or location of valvular lesions. 

With a practical knowledge of the different organic 
murmurs the situation of lesions at either of the 
orifices of the heart, or their existence at two or more 
of these orifices, may be demonstratively determined. 

By means of the murmurs, with other signs, it 
may be determined demonstratively whether the 
lesions involve obstruction or regurgitation, or both, 
or, on the other hand, that they are, as regards imme- 
diate pathological effects, innocuous. 

The murmurs do not afford definite information 
as to the amount of obstruction or regurgitation; in 
other words, as to the pathological importance or 
gravity of lesions when they are not innocuous. No 
positive conclusions on this point of view are to be 
drawn from the intensity of murmurs, their pitch, or 
their quality. As a rule murmurs which are weak, 
more than those which are loud, represent grave 
lesions. 

Pericardial Friction.^ — A pericardial or friction murmur 
is produced by the rubbing together of the surfaces 
of the pericardium in the systolic 'and diastolic move- 
ments of the heart. In the vast majority of the cases 
in which this murmur occurs it denotes either the 
presence of recent fibrin which renders the surfaces 
more or less adhesive, or roughening from fibrin which 



CARDIAC MURMURS 319 

has become dense and adherent; its diagnostic signi- 
ficance, therefore, relates almost exclusively to peri- 
carditis. In this relation it is of great practical 
importance. 

This extracardial murmur is to be discriminated from 
the endocardial murmurs. The points involved in the 
discrimination are as follows. The murmur is usually 
double, accompanying both ventricular systole and 
diastole. It can, therefore, only be confounded with 
an aortic direct and an aortic regurgitant murmur 
in combination. At the base it is not infrequent to 
hear also friction during auricular systole, and in these 
cases the 1-2-3, shuflSeboard, murmur is extremely 
characteristic. The quality of the murmur is sug- 
gestive of rubbing or friction. It is sometimes a feeble, 
grazing sound; in other instances it is loud and rough. 
When rough, the quality is expressed by such terms 
as rasping, grating, creaking, etc. Although accom- 
panying both the systolic and diastolic sounds of the 
heart, it has not that uniform, fixed relation to these 
sounds which characterizes the aortic direct and the 
aortic regurgitant murmur. It is not in definite accord 
with the heart sounds. Moreover, in intensity it 
varies with the successive movements of the heart, 
being louder with some revolutions than with others. 
In this regard it differs notably from the endocardial 
murmurs. It is not heard without the precordia, as 
a rule, and is often limited to a part of the precordial 
region; whereas certain of the endocardial murmurs 
— namely, the mitral regurgitant and the aortic direct — 



320 PHYSICAL CONDITIONS OF THE HEART 

are often heard at a considerable distance from the 
heart. Firm pressure with the stethoscope, and often 
a forced expiration, intensify the murmur. Its source 
seems very near the surface of the chest. In this 
respect it differs notably from endocardial murmurs, 
the latter appearing to come from a certain distance 
within the chest. This point of distinction is very 
appreciable, especially if, as often happens, a friction 
murmur be associated with an endocardial murmur. 
The pleuropericardial friction occurring in acute 
fibrinous pleurisy adjacent to the heart may produce 
friction sounds identical with those of true pericarditis. 
Therefore in dry pleurisy of the left anterior chest the 
diagnosis of a simultaneous fibrinous pericarditis is 
difficult. 



CHAPTER IX. 

THE PHYSICAL DIAGNOSIS OF DISEASES 

OF THE HEART AND OF THORACIC 

ANEURISM. 

Enlargement of the heart by hypertrophy and dilatation — 
Valvular lesions, mitral, aortic, tricuspid, and pulmonic — Dis- 
eases of the heart muscle — Endocarditis — Pericarditis — Func- 
tional disorders — Congenital defect — Thoracic aneurism. 

The morbid physical conditions incident to the 
different diseases of the heart and the corresponding 
signs have been considered in the preceding chapter. 
The diseases are now to be considered with reference 
to the assemblage of signs on which the physical 
diagnosis of each is to be based. Most of the diseases 
of the heart may be diagnosed by means of physi- 
cal signs. A few cardiac lesions do not admit of a 
physical diagnosis, and they do not, therefore, claim 
consideration in this work. The following are the 
affections which will form separate headings in this 
chapter: Enlargement of the heart by hypertrophy 
and by dilatation, valvular lesions, diseases of the 
heart muscle, endocarditis, pericarditis, functional 
disorders, congenital defects, and the diagnosis of 
thoracic aneurism. 
21 



322 DIAGNOSIS OF DISEASES OF THE HEART 

Enlargement of the Heart by Hypertrophy and by 
Dilatation. — Physical exploration to determine the 
size of the heart has three objects — namely, to deter- 
mine (1) that the size of the heart is normal, or (2) 
that the heart is enlarged, and (3) the degree of 
enlargement. These objects are attainable by means 
of percussion and auscultation, with considerable 
accuracy, but for truly precise delimitation of the 
heart the orthodiagraphic method with the a:-ray is 
preferable. 

The heart is of normal size when the apex beat is 
in its normal situation, that is, in the fifth inter- 
costal space, a little within the midclavicular line. 
When the superficial cardiac space is not enlarged, 
as shown by percussion and by auscultation of the 
voice (mde p. 254), and when percussion shows the 
lateral borders of the heart to be situated normally 
— namely, on the left side a little within the line of 
the nipple, and on the right side a finger's breadth 
to the right of the right margin of the sternum — 
these points of evidence warrant a positive conclu- 
sion that the heart is not enlarged, if the lung borders 
overlapping the heart are normal. 

The fact of an enlargement, and its degree, are 
determinable by an abnormal situation of the apex, 
together with an increase of the superficial cardiac 
space, and extension of the lateral boundaries of the 
deep cardiac space, especially on the left side. 

In cases of slight or very moderate enlargement, 
the apex is situated a little without the midclavicular 



ENLARGEMENT OF HEART BY HYPERTROPHY 323 

line, but not below the fifth intercostal space. A 
somewhat greater enlargement lowers the apex to 
the sixth intercostal space, and removes it farther 
without the midclavicular line. In greater degrees 
of enlargement the apex is lowered to the seventh, 
eighth, or ninth intercostal space, and generally 
farther removed to the left. 

The lowering of the apex and the removal to the 
left are not uniformly proportionate to each other. 
As a rule, if the right side of the heart be chiefly 
enlarged, the apex is removed without the midclavicu- 
lar line farther than when the enlargement of the left 
side of the heart predominates; and when the latter 
is the case, the apex is lowered out of proportion to 
its removal w^ithout that line. The relatively abnor- 
mal situation downward or to the left, thus, is evidence 
of the enlargement predominating in either the left 
or the right side of the heart. 

Generally the situation of the apex is apparent to 
the touch, and frequently to the eye. In some 
instances, however, the impulse can neither be seen 
nor felt. How is its situation to be then ascertained? 
Auscultation furnishes a ready and reliable mode of 
determining this point. The situation in which the 
first sound of the heart has its maximum of intensity 
corresponds to the situation of the apex. This is hardly 
less definite than the presence of an appreciable impulse. 

In determining the fact of enlargement and its 
degree by the abnormal situation of the apex, we 
must exclude mere lateral displacement of the heart 



324 DIAGNOSIS OF DISEASES OF THE HEART 

from extracardiac causes. The apex is removed to 
the left of its normal situation by enlargement of 
the left lobe of the liver, abdominal tumors, hydro- 
peritoneum, the pregnant uterus, and gastric tym- 
panites. These extrinsic conditions are to be excluded 
or due allowance made for them. In some cases 
in which one or more of these extrinsic causes of 
displacement may exist the apex is carried into the 
axillary region. It is to be borne in mind that these 
causes of displacement may exist when there is more 
or less enlargement of the heart. All these causes, 
while they displace the apex to the left, do not lower, 
but tend to raise it above its normal situation. On 
the other hand, an aneurismal or other tumor, situ- 
ated above the heart, may press downward the organ, 
or an unusually long first portion of the arch of the 
aorta may occur, and in this way the apex is more 
or less lowered. 

The superficial space is increased in proportion as 
the heart is enlarged. The extent of this increase 
is easily determined by percussion and auscultation. 
Within this space there is notable dulness on per- 
cussion. The degree of dulness is greater than 
within the superficial cardiac space in health, and 
this degree of dulness is proportionate to the greater 
area in which the heart is uncovered of lung. It is 
easy to delineate by percussion on the chest the 
boundary of the anterior border of the upper lobe 
of the left lung; in other words, of the oblique line 
which is the hypotenuse of the right-angled triangle. 



lU. 



ENLARGEMENT OF HEART BY HYPERTROPHY 325 

representing the superficial cardiac space in health 
and in disease. The area of the superficial cardiac 
space is also not less readily and precisely ascertained 
by auscultation of the voice; the limits of the lung 
within the precordia are denoted by an abrupt cessa- 
tion or notable diminution of the vocal resonance. 
In women with large mammae auscultation is more 
available for this object than percussion. The extent 
to which the superficial cardiac space is enlarged is 
a good criterion of the degree of the enlargement of 
the heart. 

In proportion as the heart is enlarged, the situation 
of the left border of cardiac dulness is without the mid- 
clavicular line. Its situation is determined by percus- 
sion. Dulness, although not great, is sufficiently 
distinct within the deep cardiac space, and the line 
which denotes the left border of the heart is easily 
delineated on the chest. This statement holds true 
with respect to the right border of the heart. But this 
border, even when the enlargement of the heart is 
great, is removed comparatively little to the right of 
its normal situation, except in dilatation of the right 
auricle and right ventricle in tricuspid regurgitation. 
Then it is not unusual to find the superficial cardiac 
dulness as much as three fingers' breadth to the right 
of the sternum in the third and fourth interspaces. 
By means of percussion the boundaries of the pre- 
cordia, as enlarged by the increased size of the heart, 
may be determined and measured. In making this 
statement it is assumed that the lungs are not 



326 DIAGNOSIS OF DISEASES OF THE HEART 

diseased, and that the chest is not deformed. Shrink- 
age of the upper lobe of the left lung may enlarge 
the superficial cardiac space, and cause displacement 
of the heart. The latter is an effect of the presence 
of pleuritic effusion, and it may follow its removal. 
In cases of deformity from spinal curvature, to 
determine the fact of enlargement of the heart or 
its degree is not always an easy problem. 

There is a liability to error in localizing the apex in 
some cases of enlargement. Owing to the blunted 
form of the apex, especially when the enlargement is 
chiefly of the right side of the heart, the apex beat 
may be feeble. It is likely to be overlooked, and a 
stronger impulse in the intercostal space above the 
apex be mistaken for the apex beat. Of course the 
lowest impulse is the apex beat, for the apex beat is 
the point farthest downward and to the left at which 
definite impulse is palpable; it is not the point of 
maximum impulse (P. M. I.). Careful palpation, 
and finding by auscultation the spot where the first 
sound has its maximum of intensity, will prevent 
error. 

Enlargement of the heart, and the degree of 
enlargement having been ascertained, it is to be 
determined whether hypertrophy or dilatation pre- 
dominate. If the enlargement be slight or moderate, 
it may be a question whether hypertrophy or dilata- 
tion exist alone. As a rule, if. either of these two 
forms of enlargement exist without the other, it is 
hypertrophy, for, with rare exceptions, hypertrophy 



ENLARGEMENT OF HEART BY HYPERTROPHY 327 

precedes dilatation. If the enlargement be very 
great, as a rule, dilatation predominates, for the 
capability of hypertrophic increase of size has its 
limit, and an increase of size beyond this limit must 
be due to dilatation. 

The signs, denoting on the one hand hypertrophy, 
and on the other hand dilatation, relate to the 
impulses of the heart and to the heart sounds. With 
a moderate enlargement hypertrophy is to be inferred 
from an abnormal force of the apex beat and an 
intensification of the systolic sound, especially the 
sound of muscular contraction over the apex. With 
a considerable or great enlargement, if hypertrophy 
predominate, the apex beat may be abnormally strong 
and prolonged, but, as already stated, owing to its 
blunted form, the beat is sometimes weak and scarcely 
appreciable; the increased power of the ventricular 
contractions, representing the hypertrophy, is then to 
be determined by impulses in the intercostal spaces 
above the apex. These impulses are sometimes 
present in each intercostal space between the apex 
and the base, and they are abnormally strong in 
proportion as hypertrophy predominates. Still more 
marked evidence of hypertrophy is sometimes obtained 
when the hand is placed over the precordia; a power- 
ful heaving movement is felt. The increased power 
of the ventricular contractions may, in some cases, 
be in this way appreciated somewhat as if the heart 
were held in the hand. In cases of considerable or 
great hypertrophic enlargement, the intensity of 



328 DIAGNOSIS OF DISEASES OF THE HEART 

the sound of impulsion over the apex is notably 
increased; it is prolonged, and its booming quality 
is more marked than in health. Not infrequently 
it is accompanied by a metallic ringing sound or 
tinnitus. 

Moderate enlargement by dilatation is character- 
ized hy abnormal weakness of the apex heat, and of 
the systolic sound over the apex. Cases, however, of 
simple dilatation are rare. If the enlargement be 
considerable or great, the dilatation predominating, all 
the impulses are weak, as compared with the cases 
in which hypertrophy predominates; and the muscu- 
lar element of the first sound over the apex is dimin- 
ished or nil; the feeble, short, mitral valvular sound 
either supplanting or predominating. These points 
of distinction are marked in proportion as dilatation 
predominates. 

In the great majority of the cases of enlargement 
of the heart, valvular lesions coexist. These coexist- 
ing valvular lesions are represented by endocardial 
murmurs, and they may generally be excluded by 
the absence of the latter. In most of the cases in 
which enlargement exists without valvular lesions, it 
is associated with either pulmonary emphysema or 
chronic Bright's disease. 

VALVULAR LESIONS. 

The physical diagnosis of valvular lesions embraces 
their localization at the different • orifices within the 



VALVULAR LESIONS 329 

heart, and the determination of their character as 
giving rise to obstruction and regurgitation; or of 
their innocuousness in these respects. These objects 
of diagnosis involve the endocardial murmurs and 
the abnormal modifications of the heart sounds which 
were considered in the preceding chapter. Lesions 
at the different orifices — namely, the mitral, aortic, 
tricuspid, and pulmonic — will be considered sepa- 
rately. 

Mitral Lesions. — The lesions at the mitral orifice 
are represented by the mitral murmurs — the mitral 
direct murmur, the mitral regurgitant, and the mitral 
systolic non-regurgitant or functional murmur. 
Mitral obstructive lesions exist whenever the mitral 
direct murmur is present, with an exception already 
stated and explained {vide Flint Murmur, p. 303) — 
namely, this murmur is present in some cases in 
which the mitral valve is intact; aortic lesions, giving 
rise to free regurgitation, existing in these cases. 
These exceptional instances are rare. 

Mitral regurgitant lesions cannot be diagnosed on 
the mere presence of a systolic murmur at the apex. 
A systolic murmur having its maximum of intensity at 
or near the apex, transmitted laterally for a certain 
distance beyond the apex on the left side of the 
chest, and heard on the back near the lower angle 
of the scapula, generally, if not invariably, denotes 
a regurgitant current. The evidence is still stronger 
if hypertrophy or dilatation can be demonstrated, or 
if increased pressure in the pulmonary vessels can be 



330 DIAGNOSIS OF DISEASES OF THE HEART 

shown, by accentuation of the pulmonic second sound. 
But it cannot be overemphasized that a systoHc 
murmur Hmited to a small area around the apex, or 
to the superficial cardiac space, is not proof of regur- 
gitation. A truly regurgitant murmur, however, 
may be too feeble to be transmitted beyond the apex; 
the proof of regurgitation must then be based on 
other evidence associated with the murmur — namely, 
on enlargement of the heart and abnormal modifica- 
tions of the heart sounds. 

Mitral obstruction may occasionally exist without 
incompetency of the mitral valve. The converse of 
this is of more frequent occurrence, that is, regurgita- 
tion may frequently exist without obstruction. The 
absence, however, of a mitral direct murmur is not 
positive proof against mitral lesions, for, as has been 
seen (vide p. 301), the production of a characteristic 
mitral direct murmur requires the obstruction to 
be caused by an adherence of the mitral curtains at 
their sides, the curtains being sufl&ciently flexible to 
vibrate with the passage of the mitral direct current 
of blood, and the blood flow must be sufficiently rapid 
to produce the vibrations. If these conditions for the 
production of the murmur do not exist, there ma}^ be 
no murmur produced by the mitral direct current, 
or, if a murmur be present, it is devoid of the usual 
characteristic quality. Mitral obstruction and regur- 
gitation not infrequently coexist, as shown by the 
presence of both the mitral direct and the mitral 
regurgitant murmur. A mitral murmur produced 



VALVULAR LESIONS 331 

by a mitral direct current, but diastolic in point of 
time, is frequently, as has been seen {vide p. 299), 
observed in connection with mitral stenosis. It is 
accepted now, on accurate experimental and clinical 
evidence, that the cause of the change in time of 
the mitral direct murmur, from presystolic to diastolic, 
is the progressive narrowing of the mitral orifice. 
Auricular fibrillation results in a loss of the presystolic 
propulsive force, which determines the incidence of 
the usual presystolic mitral murmur, as long as the 
auricle contracts effectively. 

Cases of mitral stenosis in which the murmur is 
absent require particular attention. Absence of the 
murmur, as stated, is due to insufficient velocity of 
the blood flowing through the obstruction. In the 
group where low velocity is present because the 
obstruction is mild, . active exertion is extremely 
useful. Extremely characteristic murmurs appear 
where a moment before nothing abnormal was found. 
But in the group where the murmur is absent, despite 
well-marked stenosis, because of a weak right heart, 
exercise is less useful and not always justifiable. Two 
other signs are of value — the snapping first sound 
(with the corresponding tapping apex beat) and the 
protodiastolic third (the "opening snap"). The for- 
mer consists in an unusually sharp, snapping, valvu- 
lar quality of the first sound frequent in mitral 
stenosis, and sometimes extremely marked. Quite 
commonly it can be heard a few inches away from the 
chest, and occasionally even from the foot of the bed. 



332 DIAGNOSIS OF DISEASES OF THE HEART 

With this type of first sound there is usually also a 
quick tap-like apex impulse, which is frequently 
equally characteristic. The cause is connected with 
the emptiness of the ventricle at the onset of systole, 
so that its contraction is unopposed until fully under 
way (vide p. 275). 

A protodiastolic third heart sound may be heard 
in normal health (mde p. 261), but it is seldom of any 
great intensity. In mitral stenosis, however, this 
third heart sound is frequently very distinct. It is 
apparently due to the sudden tension on the edges of 
the mitral valve when, with ventricular diastole, it 
starts to open widely but cannot. It may well be 
compared to the opening of a door protected by a 
chain latch; and the name "opening snap" is well 
chosen. In cases where there is doubt as to the 
presence of a mitral obstruction — either because the 
characteristic murmur is absent or because, in the 
presence of aortic insufficiency, the question of a 
Flint murmur is raised — the tapping impulse, snap- 
ping first sound, and diastolic third sound are all 
valuable evidence in favor of a mitral stenosis. 

The mitral murmurs do not per se denote the amount 
of obstruction or regurgitation, or of both combined. 
Information with reference to these points may be 
derived, in the first place, from a comparison of the 
aortic with the pulmonic second sound. The amount 
of obstruction or regurgitation, or both, is great in 
proportion as the aortic sound is weakened, or the 
pulmonary sound accentuated, or both. Per contra, 



VALVULAR LESIONS 333 

there can be but little obstruction or regurgitation, 
if the aortic and the pulmonic second sound pre- 
serve completely or nearly their normal relation to 
each other in respect to intensity. Information may, 
in the second place, be obtained by directing attention 
to the mitral valvular sound {mde p. 266). In propor- 
tion as the closure of the mitral valve is compromised 
by lesions, the mitral valvular sound at the apex will 
be weakened. 

Enlargement of the right side of the heart, which 
results from mitral obstructive and regurgitant 
lesions, is a criterion of the amount of obstruction 
and regurgitation, taken in connection with the 
length of time they have existed. Hypertrophic 
enlargement of the right ventricle intensifies the 
pulmonic second sound, and allowance must be made 
for this modification in determining, by a comparison 
of the pulmonic and the aortic sound, the degree in 
which the latter is weakened. Attention is to be 
given to the tricuspid valvular sound {vide p. 266). 
Thb intensity of this sound is, in some measure, a 
criterion of the power of the right ventricular systole. 

Aortic Lesions. — ^Lesions are localized at the aortic 
orifice by the aortic murmurs — namely, the aortic 
direct and the aortic regurgitant murmur. Aortic 
obstructive lesions give rise to an aortic direct mur- 
mur; but it must be considered, in the first place, 
that an aortic direct murmur may he inorganic, and, 
in the second place, that if the murmur be organic 
it may he 'produced hy lesions which occasion no 



ul 



334 DIAGNOSIS OF DISEASES OF THE HEART 

obstruction, and are consequently innocuous from a 
mechanical stand-point. The existence of obstructive 
lesions must be determined by evidence added to the 
presence of the murmur. This evidence is either 
diminished intensity or suppression of the aortic 
second sound, enlargement of the left ventricle, a 
systolic thrill in the aortic area, and modification 
of the pulse. If the lesions which occasion obstruc- 
tion are of a character to diminish or arrest the move- 
ments of the aortic valve, the aortic second sound will 
be either weakened or lost. If valvular lesions be 
limited to the aortic orifice, the degree of enlargement 
of the left ventricle is a criterion of their pathological 
importance, although the almost constant occurrence 
of regurgitation when aortic stenosis is present, 
detracts from the value of hypertrophy as evidence 
of the former. Excluding aneurism, a systolic thrill 
at the second right interspace is rarely found except 
in true stenosis. 

The character of the arterial pulse is of great value. 
In typical cases it is small (parvus), rises slowly 
(tardus), is prolonged (longus), and is infrequent 
(rarus). In other words, it is a slow, rounded wave, 
in absolute contrast to the sudden high-peaked wave 
of aortic regurgitation. When such a pulse is present 
it is of the greatest diagnostic significance. But it is 
by no means always present, because in the vast 
majority of cases aortic regurgitation complicates 
the picture and tends to produce a pulse of totally 
different character. In the absence of typical thrill 



VALVULAR LESIONS 335 

and pulse, the points usually to be considered are 
the degree of hypertrophy compared to the size of 
the pulse. With a pulse but slightly water-hammer 
in type we probably have to do either with a very 
slight aortic leakage with no stenosis, or else there is 
a large regurgitation combined with a stenosis which 
neutralizes the effect of the regurgitation upon the 
pulse. With moderate cardiac hypertrophy the former 
would be probable, with great hypertrophy the latter. 

Regurgitant lesions at the aortic orifice give rise 
to an aortic regurgitant murmur. This murmur, of 
course, is always proof of regurgitation; but the mur- 
mur gives no definite information concerning the 
amount of incompetency of the aortic valve. A loud 
murmur may be produced by a regurgitant stream 
so small as to be, for the time, insignificant; and, 
on the other hand, a large regurgitant current may 
give rise to a feeble murmur. The extent to which 
the valve is damaged by the lesions is to be deter- 
mined, first, by either weakness or suppression of the 
aortic sound, and second, by the degree of enlargement 
of the left ventricle. 

Aortic obstructive and regurgitant lesions are 
often associated. An aortic direct and an aortic 
regurgitant murmur are then both present, with a 
weakened aortic sound or its suppression, and enlarge- 
ment of the left ventricle according to the amount 
of the obstruction and regurgitation, together with 
the length of time during which the latter have existed. 
These effects, and not the intensity, nor the pitch, 



336 DIAGNOSIS OF DISEASES OF THE HEART 

nor the quality of the murmurs, are indicative of 
their pathological importance. 

Mitral and aortic lesions often coexist, giving rise 
to two, three, or four of the obstructive and regur- 
gitant murmurs in the left side of the heart. In 
addition to the murmurs in these cases, the effects 
of the combined lesions are shown in the modification 
of the heart sounds, and the enlargement of both 
sides of the heart. 

Tricuspid Lesions. — Tricuspid obstructive lesions are 
exceedingly rare. A few instances of the kind of 
obstruction which is represented by a tricuspid 
direct diastolic or presystolic murmur, have been 
reported. One instance has fallen under my obser- 
vation. In this case, as in the other instances which 
have been reported, the tricuspid was associated with 
mitral lesions; hence, in localizing an obstructive 
lesion at the tricuspid orifice, the presence of the pre- 
systolic murmur on each side of the heart, that is, the 
coexistence of the mitral and the tricuspid direct 
murmur is to be determined. This point has already 
been considered (vide p. 314). Signs which are 
accepted as fairly characteristic of tricuspid stenosis 
are: a diastolic or presystolic murmur at the tricuspid 
area without accentuation of the second pulmonic 
sound; often in addition an aortic lesion; an enlarged 
right ventricle and auricle, distended veins in the 
neck, frequently without pulsations ; persistent cyanosis 
of mucous membranes and skin, and marked tendency 
to edema or general anasarca with relatively little 



VALVULAR LESIONS 337 

dyspnea. The diagnosis should be made without a 
presystohc murmur, as this is inconstant. There is 
almost always coincident mitral stenosis. There is 
likely to be a pulsation recorded over the liver coin- 
cident with auricular contraction. 

Tricuspid regurgitation is not uncommon. Gener- 
ally the insufhciency is caused by dilatation of the 
right ventricle occurring as an effect of mitral regur- 
gitant or obstructive lesions. Tricuspid regurgita- 
tion is not always represented by murmur; and when 
a tricuspid regurgitant murmur is present, it is to be 
discriminated from a coexisting mitral regurgitant 
murmur. This point has been considered {vide p. 
315). A sign of free tricuspid regurgitation with 
hypertrophy of the right ventricle is pulsation of 
the liver, which may be seen and felt, and is 
synchronous with ventricular systole. This pulsation 
is sometimes notably strong. If the liver be enlarged, 
the pulsation may be communicated to the greater 
part of the abdomen, and its force may be suggestive 
of aneurism of the abdominal aorta. Pulsation of 
the liver may be observed when there is no ven- 
tricular jugular pulse, nor notable turgescence of the 
cervical veins. On the other hand, pulsation of the 
ventricular type in the cervical veins may be present 
when liver pulsation is indetectable. 

Pulmonic Lesions. — As compared with aortic lesions 
these are of infrequent occurrence, and they are 
generally congenital. Lesions giving rise to a pul- 
monic direct murmur may be localized by differen- 
22 



338 DIAGNOSIS OF DISEASES OF THE HEART 

tiating this murmur from the aortic direct murmur 
(vide p. 315). It is to be considered that an inor- 
ganic pulmonic direct murmur is not infrequent. 
Pulmonic regurgitant lesions can only be diagnosti- 
cated by determining that a murmur is produced at 
the pulmonic, and not at the aortic orifice {vide p. 
316). 

DISEASES OF THE HEART MUSCLE. 

None of the diseases of the heart muscle is repre- 
sented by distinctive physical signs, but, nevertheless, 
the physical diagnosis taking into account the clinical 
history, may be quite positive. The signs, as well as 
the symptoms, are those which denote persistent 
muscular weakness of the heart. The most marked 
evidence is notable weakness of the systolic sounds, 
and especially weakness or suppression of the muscular 
element of the first sound. In the acute degeneration 
of the myocardium which accompanies acute infectious 
fevers, enfeeblement or disappearance of the apex 
beat and weakness of the systolic sounds are the only 
signs, and the symptoms are only part and parcel of 
the symptoms of the underlying disease. The same 
is true of the brown atrophy of the heart which occurs 
in wasting diseases, such as tuberculosis and cancer. 

In the more serious changes of acute infectious 
myocarditis, as seen in diphtheria, acute articular 
rheumatism, some cases of pneumonia and influenza, 
and rarely in other infections, may be added the 
signs of dilatation of the heart, with or without a 



DISEASES OF THE HEART MUSCLE 339 

functional mitral regurgitation. The symptoms of 
muscular weakness of the heart become prominent, 
and various disturbances of rhythm may arise from 
damage to areas of the heart having specialized 
functions. 

Heart-muscle weakness is a part of the clinical 
picture of anemia of any severity. Here some dila- 
tation is the rule, the apex beat is more diffuse, the 
impulse sudden, the sound of contraction feeble, the 
systolic sound valvular in quality. A systolic mur- 
mur is heard over the pulmonary artery; also, as a 
rule, a mitral regurgitant murmur, due to dilatation 
of the mitral orifice. In the more severe fatty degen- 
eration of the heart of pernicious anemia, similar 
signs are found, but the enlargement is more marked, 
hypertrophy and dilatation being usual, and the 
murmurs are more pronounced. Venous hum in the 
neck is helpful in the diagnosis of the heart muscle 
weakness of anemia (vide p. 309). 

Chronic myocarditis, as a sequel of acute mj^o- 
carditis of coronary artery disease with multiple 
small infarctions (fibroid myocarditis), or primar}^, 
as in syphilitic myocarditis, the fatty heart, and other 
chronic affections of the myocardium, cannot be 
distinguished from one another with certainty during 
life. The most that can be attempted wisely is the 
diagnosis of chronic myocardial disease or weakness, 
and its discrimination from myocardial weakness 
secondary to chronic valvular disease, adherent peri- 
cardium, the hypertrophy of Bright's disease, emphy- 



340 DIAGNOSIS OF DISEASES OF THE HEART 

sema, and so forth. The most important physical 
sign is the loss of the sound of muscular contraction 
at the apex, the systolic sound which is heard being 
chiefly or exclusively the mitral valvular sound. 
This sound is short and valvular in quality, like the 
diastolic sound. The apex beat may be feeble, or 
diffuse and shock-like. If the heart be dilated, the 
apparent force of the apex beat is in contrast to the 
feebleness of the radial pulse. With dilatation, 
functional mitral, and also tricuspid, regurgitation 
may occur, and reach such a grade as to render the 
discrimination from primary mitral valvular disease 
difficult, if not impossible. The history of past acute 
articular rheumatism, or a known mitral murmur, 
is of special importance in making the decision. In 
muscular weakness a systolic murmur at the apex 
may be brought out only by exercise. This should 
always be sought for. 

Various disturbances of rhythm may occur (vide 
p. 283) of which the most important are heart-block, 
due to a lesion involving the atrioventricular bundle, 
and the complete irregularity^ which denotes auricu- 
lar fibrillation. When the latter exists, it may be 
difficult or impossible to distinguish primary myo- 
cardial disease from mitral obstruction after the 
disappearance of the mitral direct murmur (vide p. 
301). Here, again, the history is of more value than 
the physician signs. 

Endocarditis. — The physical diagnosis of endocardi- 
tis relates especially to its occurrenc*e in connection 



DISEASES OF THE HEART MUSCLE 341 

with articular rheumatism. A variety of murmurs 
may occur, the commonest one, and one upon which 
the diagnosis is often based, is a mitral systolic but 
not necessarily organic murmur. The presence of 
this murmur, however, in a case of rheumatism, is 
not positive proof of an existing endocarditis, more 
especially if the patient had previously had articular 
rheumatism, because an endocarditis developed in a 
previous attack may have left a permanent murmur. 
If the murmur be a mitral regurgitant murmur, and 
the heart be definitely hypertrophied, it is quite 
certain that endocarditis has occurred previously. 
The appearance of the murmur during an attack of 
rheumatism, when previous examination had shown 
none, particularly if accompanied by enlargement 
and accentuation of the pulmonic second sound, is 
usually indicative of endocarditis; although slight 
mitral leakage due to dilatation of the ring is fre- 
quently present as a result of myocardial weakness. 

An aortic direct murmur, in cases of rheumatism, 
is not evidence of endocarditis, because in many cases 
of rheumatism this murmur occurs, and is to be 
regarded as inorganic. 

In the variety of endocarditis, known as ulcerative, 
occurring in the course of infectious or septic dis- 
eases, and sometimes without any known point of 
entrance of the infecting organism, an aortic mur- 
mur may be developed, with or without a coexisting 
mitral murmur, owing to the soft masses present on 
the valves. 



342 DIAGNOSIS OF DISEASES OF THE HEART 

Acute endocarditis is probably of frequent occur- 
rence as secondary to pre-existing mitral and aortic 
valvular lesions; but, under these circumstances, a 
physical diagnosis is impracticable unless definite 
change in the character and intensity of the murmur 
occurs, or fever, enlarged spleen, and petechial spots 
are present. 

Pericarditis. — The physical diagnosis of pericarditis 
in the first stage, that is, prior to the effusion of liquid, 
is to be based on a pericardial friction murmur. For- 
tunately for diagnosis, this murmur is uniformly 
present, though at times for only a brief period. Its 
characters as contrasted with endocardial murmurs 
have been stated (vide p. 218). The presence of a 
pericardial friction murmur, in connection with 
symptoms denoting pericarditis, renders the diag- 
nosis quite positive. There is, however, one liability 
to error. In some cases of pleurisy or pneumonia 
with pleuritic inflammation, the movements of the 
heart occasion a rubbing together of the roughened 
pleural surfaces, and in this way a cardiac pleural 
friction murmur is reproduced (pleuropericardial) . 
This may be single or double, and when double, it 
simulates the murmur produced within the pericardial 
sac. It is limited to the border of the heart, and is 
neither accompanied nor followed by pericardial 
effusion. Of course the error of mistaking a cardiac 
pleural friction murmur for one produced within the 
pericardium can only occur when pleurisy exists, 
either as a primary affection or as secondary to pneu- 
monia, or- to pulmonary tuberculosis. 



DISEASES OF THE HEART MUSCLE 343 

In the second stage of pericarditis, that is, after 
the effusion of hquid has taken place, the pericardial 
friction murmur often, but not always, disappears. 
The physical diagnosis in this stage is then to be 
based on the signs which show the presence of a 
greater or less quantity of liquid within the pericardial 
sac. The signs which denote pericardial effusion, 
and its amount have been stated (vide p. 273). With 
a moderate effusion the apex of the heart is raised, 
and the apex beat may be felt in the fourth inter- 
costal space, and removed to the left of its normal 
situation. With considerable or large effusion the 
apex beat is lost, and the sounds of the heart are 
feeble and distant. The muscular quality of the 
first sound is lost, leaving the mitral and tricuspid 
sounds, which are short and valvular like the diastolic 
sounds. 

Increase or diminution of liquid in the second stage 
of pericarditis is readily determined by signs obtained 
by percussion and auscultation. When the quantity 
is much diminished, the friction murmur, if it has 
been suppressed, returns, and persists until the peri- 
cardial surfaces become agglutinated. Not infre- 
quently, by auscultating when the body of the 
patient is inclined forward, a friction murmur may 
be heard, notwithstanding the pericardial sac contains 
a large quantity of Hquid. 

In cases of chronic pericarditis with very large 
effusion, dilatation of the pericardial sac is shown 
by signs obtained by percussion and auscultation. 



344 DIAGNOSIS OF DISEASES OF THE HEART 

There is no apex impulse, the heart sounds are feeble 
and distant, the systolic sounds being short and 
valvular, and .the precordia may be notably project- 
ing. There may be systolic retraction at or near the 
apex beat. Dulness with soft bronchial breath sounds 
may be found in the left infrascapular region as a 
result of compression of the lung. 

A malignant growth filling the pericardial sac 
and inclosing within it the heart may give rise to 
all the signs of pericardial effusion. A case of this 
kind, in a young subject, has fallen under my obser- 
vation. 

With reference to diagnosis, the etiological rela- 
tions of pericarditis should be kept in mind. These 
are acute articular rheumatism, Bright's disease, 
tuberculosis, and either pleurisy or pneumonia. It 
rarely occurs in other connections; and, as an 
idiopathic affection, it is extremely rare. 

The presence of air and liquid within the pericar- 
dial sac gives rise to loud splashing sounds which, 
occurring when respiration is suspended, and when 
hydropneumothorax is excluded, are at once diag- 
nostic of hydropneumopericardium. 

FUNCTIONAL DISORDERS. 

Many of the so-called functional disorders of the 
heart are now recognized as due to distinct localized 
lesions of such parts of tlie heart and great vessels as 
have to do with the origination and conduction of 



FUNCTIONAL DISORDERS 345 

cardiac contractions. For a summary of these the 
reader is referred to the description of irregularities 
of the pulse on page 283. 

There are other groups of symptoms, in which 
disorder of heart action plays an important role, 
which have no constant or at present recognized 
structural cause, and some are evidently temporary 
disturbances of reflex cardiac nervous mechanism. 

We may consider here angina pectoris, exophthalmic 
goitre, and palpitation. 

By angina pectoris we mean an attack, or recurring 
attacks, of severe substernal pain, which is apt to 
radiate into the arms, and especially to the left arm, 
and is accompanied by a sense of impending death. 
In the majority of cases this is found to be due to 
obliterative diseases of the coronary arteries, and 
more particularly the orifices of these arteries at 
their origins in the aorta, this being often merely a 
part of a general or extensive aortitis. 

Examination of the heart during or between attacks 
may reveal nothing abnormal. It is upon the history 
and symptoms of the case, and not upon the physical 
findings, that the diagnosis is based. 

Among the causes of rapid heart action is exoph- 
thalmic goitre, in which the most constant of the 
three cardinal symptoms — enlarged thyroid, exoph- 
thalmos, and tachycardia — is the persistently rapid 
heart action, which slows with improvement, and 
increases in rate as the patient's condition grows 
worse. Here, again, there is no constant physical 



346 DIAGNOSIS OF DISEASES OF THE HEART 

finding to account for the tachycardia, and at present 
we must class this among the symptoms due to a 
disorder of nutrition, of which the nervous unstabihty 
and loss of weight are other evidences. 

By palpitation we mean a conscious distress in the 
region of the heart or epigastrium, accompanied by 
tumultuous, excessive, rapid, and often vigorous 
heart action. In some people this can be brought 
about by relatively slight reflex irritation, a sudden 
emotion of fear or joy, or indigestion, or it may 
develop during sleep, and without apparent ante- 
cedent irritation of any kind. The subjective symp- 
toms, the manner of development, and the discovery 
of wholly normal conditions on physical examination, 
serve to make the diagnosis. 

Palpitation as a subjective symptom may occur in 
failure of, or failing, compensation, in cases of high 
arterial pressure, and in cases of mitral stenosis, 
particularly among cardiac valvular disorders. It 
may accompany attacks of paroxysmal tachycardia, 
but its association with this condition is not constant, 
nor is subjective cardiac distress at all a constant 
accompaniment of even severe grades of advanced 
valvular disease with failing compensation. 

In one point of view the physical diagnosis in 
functional disorders may be said to rest, not on 
negative, but on positive evidence. Percussion and 
auscultation afford the means, not only of exclud- 
ing inflammatory affections and lesions, but of 
demonstrating the fact that the organ is sound at 



FUNCTIONAL DISORDERS 347 

least as regards freedom from ordinary lesions. That 
its size is normal is shown by the normal situation of 
the apex beat, of the lateral boundaries of the pre- 
cordia, and of the area of the superficial cardiac 
space. That the valves are unaffected is shown by 
the normal characters of the heart sounds. These 
positive facts, taken in connection with the absence 
of morbid signs, render the diagnosis certain. Posi- 
tive assurance of the soundness of the organ should 
be withheld until painstaking examination of the 
heart, not only by auscultation and percussion, but 
by all the various accessory methods, such as the 
cc-ray and electrocardiograph, have been carried out. 
Thus will the opinion of the examiner carry the 
weight which is desirable, in order to secure for the 
patient relief from anxiety and apprehension. 

Functional disorders are not infrequently asso- 
ciated with lesions with which they have no essential 
pathological connection. A patient with lesions 
which are either innocuous or attended with little, 
if any, inconvenience, may suffer from disturbance 
of the action of the heart produced by causes which 
are wholly independent of the lesions. There is a 
liability, in these cases, to the error of attributing 
the disorders to the lesions, and thus forming an 
exaggerated estimate of the importance of the latter. 
To decide how much of the disturbed action of the 
heart is due to a superadded functional affection is 
not as easy as to determine that lesions do not exist. 
The decision must be based on the character, degree. 



348 DIAGNOSIS OF DISEASES OF THE HEART 

or extent of the lesions, as evidenced by the physical 
signs. In this connection may be stated a practical 
maxim which it is well to bear in mind whether 
functional disorders exist or not — namely, valvular 
lesions rarely give rise to much inconvenience until 
they have led to enlargement of the heart; and 
enlargement, either with or without valvular lesions, 
as a rule, does not lead to the serious effects which 
are characteristic of cardiac disease, so long as the 
enlargement is due to predominant hypertrophy, and 
not to dilatation. 

CONGENITAL CARDIAC DEFECTS. 

There are three kinds of cardiac defects which 
give signs of enough constancy to be susceptible of 
diagnosis during life. They are transposed viscera, 
i. e., a right-sided position of the heart, spleen, and 
stomach with a left position of the liver; defects of 
closure between the systemic and pulmonary circuits, 
^. e., patent interauricular septum (patent foramen 
ovale); patent interventricular septum; patent ductus 
arteriosus, or ductus Botalli; defects in the formation 
of the tricuspid or pulmonary valves resulting in 
stenosis. 

The signs of a right-sided position of the heart 
on inspection, palpation, percussion, and auscultation 
differ from the signs obtained in normal individuals 
simply in the change from the left to the right of 
the midline. This condition must be sharply dis- 



CONGENITAL CARDIAC DEFECTS 349 

tinguished from a merely displaced heart resulting 
from acquired inflammatory processes within the 
chest, or the pressure of tumors, pneumothorax or 
pleural exudates; and, of course, unaccompanied by 
the transposition of the abdominal viscera. 

Patent foramen ovale may give no signs and inter- 
fere in no way with the life of the individual. It may 
cause death. There may be cyanosis and clubbing 
of the fingers. There may be a harsh systolic mur- 
mur, heard best over the second, third or fourth 
left interspaces, and not transmitted along the pul- 
monary artery. The murmur may be diffuse. It 
may be presystolic in time and it may be both diastolic 
and systolic. 

' Perforate interventricular septum may be congenital 
or acquired. It is one of the commonest congenital 
lesions and is frequently combined with pulmonary 
stenosis. The two causes of origin are to be distin- 
guished by the history and records of examinations 
of the heart at different times. The usual signs 
are: Cyanosis, clubbing of the fingers, and bulging 
precordium, all of w^hich may be absent; a thrill over 
the precordium, extending throughout systole, and a 
loud, rough systolic murmur heard best at the third 
or fourth left interspaces, near the sternum, and 
widely diffused downward to the left, and usually 
audible in the back. 

Patent ductus arteriosus (ductus Botalli) presents 
fairly constant signs. There is usually a visible sys- 
tolic pulsation in the second left interspace. There is 



350 DIAGNOSIS OF DISEASES OF THE HEART 

a systolic thrill which may even continue through 
diastole. There are the signs of dilatation and hyper- 
trophy of the right ventricle. There is an increase of 
dulness to the left of the sternum, running from third 
to first rib, and across the manubrium of the sternum 
about 1 or IJ inches wide, indicating the dilated pul- 
monary artery. There is usually a loud systolic 
murmur of maximum intensity at the second or third 
left interspace, transmitted up to the top of the ster- 
num and left clavicle. There may be an increased 
pulmonary second sound. 

For diagnosis of tricuspid and pulmonary stenosis 
the reader is referred to descriptions of these lesions 
on pp. 315 and 336. 

THORACIC ANEURISM. 

In thoracic aneurism the physical conditions con- 
cerned in the production of signs, are: (1) A tumor 
within the chest, of variable size, formed by the 
aneurismal sac; (2) pulsation of the tumor from the 
passage of blood into the sac with each ventricular 
systole, and the expulsion of blood in the diastole by 
the recoil of the coats of the aneurism; (3) the size 
of the opening into the sac as affecting the quantity 
of blood which it receives with each systole; (4) the 
quantity of stratified fibrin which the sac contains; 
(5) the point of connection with the aorta of the 
aneurismal tumor; and (6) the direction in which the 
tumor extends, together with its relations to the 



THORACIC ANEURISM 351 

lungs, the trachea, the primary bronchi, the intratho- 
racic veins, the esophagus, the recurrent laryngeal 
nerve, the sympathetic nerve, either the innominate 
or subclavian artery, the ribs, sternum, and vertebral 
column. 

With reference to diagnosis, it is well to bear in 
mind that, in the majority of cases, an aortic aneurism 
is connected with either the ascending portion, or the 
junction of the ascending and the transverse portion 
of the arch, and that the tumor generally extends 
to the right in a lateral or anterolateral direction. 
The physical diagnosis is more easily made when the 
aneurismal tumor is thus directed. The signs are 
l^ss available if the aneurism arise from the trans- 
verse or descending aorta, and especially if the tumor 
extends in a direction downward or backward. 

An aneurismal tumor which has made its way 
through the walls of the chest, or which, without 
perforation, causes a circumscribed bulging obvious 
to the eye and touch, presents the following diag- 
nostic signs: An impulse is seen and felt which is 
synchronous with the ventricular systole. The force 
of the impulse is variable, depending, aside from the 
force with which the left ventricle contracts, upon the 
size of the orifice between the sac and the artery, and 
the quantity of fibrin which the sac contains. Follow- 
ing the impulse and coincident with the closure of the 
aortic valves, a shock (the diastolic shock of the second 
sound) may often be perceived if firm pressure be 
made with the hand. This is due to the vibration 



352 DIAGNOSIS OF DISEASES OF THE HEART 

caused by closure of the aortic valves being accent- 
uated by the resonator action of the sac wall in 
aneurisms of the ascending and transverse arch. A 
vibration or thrill with each impulse is sometimes a 
marked sign, but is often wanting. Frequently, but 
by no means constantly, a systolic murmur is heard 
over the tumor, and there may be also a diastolic 
murmur produced by the passage of blood from the 
sac. Dilatation of the first portion of the arch of the 
aorta usually occurs, of a sufficient degree to establish 
an aortic regurgitation with its characteristic murmur. 
The heart sounds are transmitted to the tumor with 
more or less increased intensity. There is notable 
dulness on percussion over an area corresponding to 
the space within the chest which the tumor occupies. 
If the tumor be of considerable size, it may produce 
condensation of lung around it; the area of dulness 
on percussion will be in this way extended beyond 
the limits of the tumor. Under these circumstances, 
bronchial respiration and bronchophony may be pro- 
duced. Pressure upon the superior vena cava caus- 
ing dilatation of the corresponding veins is frequent. 
If the aneurismal sac be beneath the integument, 
there may be to the touch a sense of fluctuation. 

With the foregoing signs, the physical diagnosis 
scarcely adinits of doubt. Some of the signs may be 
produced by a tumor, not aneurismal, so situated as to 
receive and conduct the aortic impulse. The chances 
of a tumor being so situated as to stimulate the signs 
of an aneurism are few. I have met with a case of 



THORACIC ANEURISM 353 

empyema in which perforation of the chest took 
place in the second intercostal space on the right 
side of the sternum, giving rise in this situation to a 
fluctuating tumor which had a strong pulsation. On 
a superficial examination the case seemed clearly 
one of aneurism; but an examination of the chest 
showed the right pleural cavity to be filled with 
liquid, and a puncture in the axillary region gave exit 
to a large quantity of pus, the pulsating tumor dis- 
appearing after a certain quantity of the purulent 
liquid had escaped. I have met with a similar pulsating 
tumor, incident to empyema, on the posterior aspect 
of the chest. 

When, from its small size or its situation, an aneu- 
rismal tumor does not come into contact with the 
thoracic wall, and when it is situated beneath the 
sternum, signs obtained by palpation and inspection 
being absent, the physical diagnosis is less easy. 
Important signs are: dulness within a circumscribed 
space situated in the course of the aorta; an abnor- 
mal transmission of the heart sounds within this 
space, and the presence of murmurs. These signs 
are not always available, and when present they are 
not sufficient for a positive diagnosis. Other phys- 
ical evidence, and the presence of certain symptoms, 
render the existence of aneurism highly probable, 
either with or without the foregoing signs. If an 
aneurismal tumor press upon the trachea, it occa- 
sions a tracheal rale, or stridor, together with weak- 
ness of the respiratory murmur on both sides of the 
23 



354 DIAGNOSIS OF DISEASES OF THE HEART 

chest. Less degrees of tracheal compression are 
demonstrable by the stridulous cough, which may 
be readily imitated by firm pressure with the thumb 
in the suprasternal notch. If the tumor press upon 
a primary bronchus, it occasions diminished or sup- 
pressed respiratory murmur on one side, and increased 
respiratory murmur on the other side of the chest. 
These physical signs should always lead to a suspicion 
of aneurism in a person over forty years of age. 
Symptoms which should excite this suspicion and 
lead to careful physical exploration for the physical 
signs of aneurism are: dyspnea from spasm or 
paralysis of the muscles of the glottis, and aphonia 
or impairment of the voice without evidence of 
laryngitis; these symptoms denoting either excita- 
tion or pressure of the recurrent laryngeal nerve; 
inequality of the pupils due to pressure upon the 
cervical sympathetic; dysphagia from pressure upon 
the esophagus; congestion of the face, neck, and 
upper extremities from obstruction of the vena cava 
or the vena innominata; inequality of the radial, 
carotid, and subclavian pulsation on the two sides, 
or the absence of pulsation on one side, and con- 
traction of one of the pupils. A valuable sign in 
aneurisms of the transverse to descending aorta, just 
those cases in which percussion and auscultation may 
prove negative, is the tracheal tug. This consists in 
a downward movement of the larynx with systole 
due to pulsations of an aneurism pushing down the 
left bronchus. It is detected by lifting the cricoid 



THORACIC ANEURISM 355 

cartilage upward between the thumb and forefinger. 
The erect posture is usually essential and the head 
should not be thrown backward. These symptoms 
not only render probable the existence of aneurism, 
but indicate its situation as regards the aorta and 
the direction in which the aneurismal tumor extends. 

An aneurism may be suspected, wrongly, when, 
owing to shrinkage of the lung, or deformity of the 
chest, either the aorta or the pulmonary artery just 
above the heart is removed laterally from its normal 
situation, or brought into contact with the walls of 
the chest in the second intercostal space, so as to 
give rise to an appreciable impulse. A murmur may 
also be present at the point of impulse. An error 
of diagnosis under these circumstances is avoided by 
finding an adequate explanation of the signs just 
noted, and by the absence of other signs and of symp- 
toms which are diagnostic of aneurism. 

In conclusion, an aortic murmur, however intense 
or rough, is never evidence of aortic aneurism, and, 
on the other hand, the absence of murmur is by no 
means sufficient for the exclusion of aneurism. 



CHAPTER X. 
EXAMINATION OF THE ABDOMEN. 

Inspection — Palpation — Percussion — Auscultation — Stomach 
— Liver — Spleen — Kidneys — Abdominal wall — Other organs. 

In making an examination of the abdomen it is 
presupposed that the anatomy and physiology of 
the walls and viscera have been already mastered. 
The important points of the change of position of the 
abdominal contents during respiration; the change 
in size and position of the parts of the gastro-intestinal 
tract according to the amount and character of their 
contents; the changes incident to filling and emptying 
of the bladder; the alterations in the size and position 
of the uterus must all be kept in mind while examining 
the abdomen. 

Inspection. — On inspection we note the occurrence 
of normal or abnormal shadows, betraying the move- 
ments of viscera from the descent of the diaphragm, 
or in the course of peristalsis of their muscular walls. 
Prominences can be detected, especially with the eyes 
on the level of the abdomen, and the patient's feet 
toward the source of light, in the recumbent position. 
Pulsations are noticed. It is normal to see an epi- 
gastric systolic impulse. Peristalsis is not visible 



PALPATION 357 

under normal conditions of the gastro-intestinal tract 
except in extreme emaciation. Visible peristalsis 
almost invariably indicates obstruction, and the site 
of the obstruction may often be located by close 
attention to the direction and point of cessation of 
the peristaltic waves. Peristaltic waves may be seen 
in the colon when there is extreme or acute obstruc- 
tion, which go in the normal and in the reverse direc- 
tion. The lower and upper limits of the stomach, the 
lower border of the spleen and liver, the level of the 
uterus or a distended bladder may be observed on 
inspection. Tumor masses may be noticed as abnormal, 
fixed or movable prominences as shown by shadows. 
We observe the presence of obesity, the relaxed, pen- 
dulous, or contracted and sunken parietes. We look 
for edema, the rounded abdomen of meteorism, the 
bulging flanks of ascites, dilated veins, paying particular 
attention to the system which is enlarged and the 
direction of flow. We notice whether there is support 
by the abdominal walls of their contents, or whether 
there is a general splanchnoptosis or prolapse of the 
viscera with downward and forward displacement. 
Inspection should be made in the dorsal, lateral, and 
erect positions. 

Palpation. — Palpation of the abdomen is to be done 
with the patient in the lateral or dorsal positions, the 
abdominal walls being relaxed by drawing up the 
knees and raising the head on pillows. The examining 
hands should be warm and dry. To effect perfect 
relaxation examination mav be made in a warm bath. 



358 EXAMINATION OF THE ABDOMEN 

or in extreme need under anesthesia. It may be neces- 
sary to empty the stomach, rectum, and bladder. We 
note resistance, fluctuation, the presence of a fluid wave, 
tumor masses, sensitiveness to pressure, the movable 
borders of viscera, or the outlines of deeply seated and 
fixed organs. We may note aortic pulsation, the pres- 
ence of mesenteric and retroperitoneal glands, and the 
anterior surface of the vertebrae in thin subjects. 
Errors may arise from reflex muscular tension, fat 
masses in the omentum, or mesentery, or attached 
to the gut, and from fecal masses. 

Percussion. — Percussion of the abdomen is a less 
reliable guide than palpation. The note becomes 
more resonant with increase of gas in the intestine 
or in the free peritoneal cavity, but with extreme dis- 
tention of the intestine the note loses its tympanitic 
quality; if there is gas in the free cavity there may be 
shifting dulness from coincident fluid exudate. There 
may be obliterated liver dulness whether the gas be free 
or in the intestine. The note is dulled by a diminution 
of gas in the intestines; presence of localized solid or 
fluid contents in the intestines; presence of localized 
inflammatory or neoplastic tissue superficially situated; 
by fluid accumulation in the free cavity, in which case 
the line of dulness or flatness should shift with the 
patient's change of position; and by thick abdominal 
walls. 

Percussion of the stomach, colon, and small intestines 
is unreliable as compared with inspection and palpa- 
tion; although very light percussion, or auscultatory 



STOMACH 359 

percussion will give fairly accurately the limits of 
stomach and colon if distention with gas or fluid is 
used to exaggerate the notes. 

Percussion of the borders of liver and spleen is merely 
confirmatory of facts better observed on palpation. 

Percussion of the distended bladder gives marked 
dulness if a light stroke is used. 

Percussion oA^er the enlarged uterus gives a similar 
change of note, but palpation, catheterization, and 
vaginal examination serve to prevent confusion in 
this instance. 

Percussion of the kidneys is unprofitable. 

Auscultation. — Auscultation, except as combined 
with percussion, gives no positive results of value 
except in identifying the occurrence and location of 
the fetal heart sounds, the uterine, placental, and 
cord murmurs in pregnancy; murmurs due to the 
pressure of tumors on the abdominal aorta, or over 
abdominal aneurisms; those from compensatory veins 
in hepatic cirrhosis; and friction rubs in perihepatitis 
and perisplenitis. 

STOMACH. 

Examination of the stomach should include a deter- 
mination by palpation and inspection of its size, 
location, character of its contractions, and its outlines 
when empty and when distended. Visible peristaltic 
waves seen passing from the left hypochondrium across 
the abdomen to end at the right of the umbilicus in a 
temporary prominence are diagnostic of pyloric stenosis. 



360 EXAMINATION OF THE ABDOMEN 

Points or areas of acute tenderness may be made out 
over its surface. Tumors of its walls or of the pylorus 
may be detected. By dipping or quickly striking the 
wall over the stomach we may elicit splashing when 
the stomach contains food, thus indicating its ability 
to empty itself, or its motility and the patency of the 
pylorus. In spite of the apparent accuracy of some of 
these methods combined with the use of the stomach 
tube, there is no question that reliable x-ray examina- 
tions will give us more exact data as to size, location 
and function than all the other methods combined, and 
this is equally true with regard to the other parts of 
the intestinal tract. 

LIVER. 

" The liver may be palpable in health owing to unusual 
shape of the costal margin or angle, or when displace- 
ment downward has resulted from faulty position or 
dress. The border may be palpable under these condi- 
tions even though its consistency is not unduly resistant. 
The liver may be displaced downward, or upward, 
in hydro- or pneumothorax, or in hydropericardium, 
and in meteorism, ascites, and pregnancy. The gall- 
bladder may be palpable and detected on percussion, 
to the right of midclavicular line at the costal margin, 
if it is distended by any of the obstructive affections 
which may interfere with the patency of the cystic 
duct. Enlargement occurs in the direction of the 
umbilicus. Detection of tenderness in the region of 



LIVER 361 

the gall-bladder, or just below it, may be an important 
point in distinguishing affections of the gall-bladder 
from more or less general abdominal pain, or appen- 
diceal or gastric pains. Auscultation may determine the 
presence of friction on respiration. 

We find a slight enlargement of the liver in acute 
catarrhal jaundice. 

In liver abscess the liver may be painful, irregularly 
increased in size and give friction on auscultation. 

In interstitial hepatitis (cirrhosis) there is usually 
uniform enlargement. The surface is firm and resistant, 
the edge hard, and unevenness may be detected. The 
spleen is usually enlarged as well. There is apt to be 
slight icterus, enlargement of superficial abdominal veins, 
and ascites. 

In carcinoma of the liver there is unequal enlarge- 
ment and a lumpy surface; there is usually icterus and 
ascites, but the spleen is not enlarged. 

In echinococcus cyst of the liver there may be a 
fluctuating tumor. Icterus is often present. The 
spleen is not enlarged, and ascites is not present. 

In chronic passive congestion of the liver we find 
an enlarged, firm, sometimes tender and often pul- 
sating liver. Icterus may occur but does not persist. 
The spleen is not enlarged, and ascites is not present, 
unless there is edema of dependent parts of the body 
or hydrothorax as well. 

The liver may be enlarged in syphilis, when we 
find it hard and lumpy. The spleen frequently large; 
ascites and icterus present or absent. 



362 EXAMINATION OF THE ABDOMEN 

The amyloid liver is evenly enlarged, and smooth 
and firm. The spleen is enlarged. No icterus or ascites. 

In leukemia the liver is enlarged but to a less degree 
than the spleen. No icterus or ascites. 

The liver is decreased in size in atrophic forms of 
chronic hepatitis, and in acute yellow atrophy of the 
liver. In the former we find an enlarged spleen, much 
ascites, slight icterus. In the latter we have extreme 
icterus, without enlargement of the spleen, or ascites. 

SPLEEN. 

The outlines of the spleen can be determined by 
percussion, except for its posterior pole {vide p. 81). 

By palpation the lower pole of the spleen is to be 
felt if the spleen is enlarged. Palpation should always 
be carried out in two ways, unless the spleen is easily 
felt. With the patient in the dorsal position the 
examiner faces the patient, standing on his right side, 
and palpates gently with the flat of the fingers in the 
left hypochondrium, at or just beneath the costal 
margin at the anterior axillary line and also at about 
the midclavicular line. It is advantageous to simul- 
taneously lift upward with the right hand in the upper 
left lumbar region. The patient is directed to breathe 
in deeply, and as the diaphragm descends the soft 
tip of the spleen will be felt, with moderate enlarge- 
ment. Relaxation of the anterior pressure just at the 
height of inspiration often allows the spleen to flip 
under the finger-tips, producing a very characteristic 



KIDNEYS 363 

sensation. If this procedure fails, the examiner should 
stand at the patient's back while the patient lies upon 
his right side. The examiner may palpate as before 
or else, facing toward the patient's feet, hooks the 
fingers of his right hand over the costal margin, to feel 
the spleen as it is forced down in inspiration. When 
the spleen is markedly enlarged it may be missed if 
the examiner's hand is applied too near the ribs or too 
far posteriorly in the flank. Tenderness and uneven- 
ness of the margin may be observed. 

If the splenic flexure of the colon is full of feces, the 
splenic dulness cannot be made out. If the stomach 
contains food, percussion over the spleen must be made 
with the patient on his right side. 

Emphysema, meteorism, or ascites may cause a 
loss of splenic dulness. If the spleen is palpable, or 
the dulness reaches the anterior axillary line the spleen 
is enlarged. Enlargement occurs in many infectious 
diseases, especially in typhoid fever, and in malaria, 
typhus fever, aciite endocarditis, and sepsis. The 
spleen is enlarged in cirrhosis of the liver, infarct of 
the spleen, amyloid disease, and the true and pseudo- 
leukemias. The spleen may be enormously enlarged 
without apparent cause in tropical diseases, splenic 
anemia, polycythemia, splenomegaly, and Banti's 
disease. 

KIDNEYS. 

The kidneys cannot be percussed with profit. 
Changes of size and position can usually be determined 



364 EXAMINATION OF THE ABDOMEN 

by palpation. Palpation is used with the patient 
lying on his back, side, or abdomen, or in a semi-erect 
seated posture. An effective way of detecting a mov- 
able kidney is to grasp the abdominal wall gently with 
one hand, the palmar surface of the fingers against the 
lumbar muscles and the thumb pressing backward. 
The lower pole of the kidney if it descends on inspira- 
tion forces the thumb and fingers apart. By using 
bimanual palpation with one hand behind, just below 
the eleventh rib, and the other pressing back against 
the abdominal wall, the posterior hand appreciates 
increased resistance, as an enlarged kidney is forced 
down in inspiration. An enlarged spleen is not pal- 
pable posteriorly. When freely dislocated even the 
upper pole may be palpated. Enlarged kidneys are not 
so easily felt, nor do they so often move with the dia- 
phragm, as do prolapsed kidneys. The colon is usually 
pressed forward by an enlarged kidney in contrast to 
being pressed backward by an enlarged spleen, the 
relative positions of colon and kidney being readily 
ascertained after artificial distention of the colon with 
gas. 

ABDOMINAL WALL. 

Abdominal distention occurs in meteorism, which 
is a common incident in enterocolitis, typhoid fever, 
in peritonitis, and in obstruction of the gut. In peri- 
tonitis there is extreme tenderness either generalized, 
or, if the process is localized, as an appendiceal abscess, 
inflamed gall-bladder or ruptured gastric or intestinal 



ABDOMINAL WALL 365 

ulceration, the tenderness may be sharply circum- 
scribed, with muscular spasm extending more or less 
widely. At a point half-way between the anterior 
superior spine of the ilium and the umbilicus, the 
tenderness of appendiceal inflammation is usually 
sharply localized (McBurney's point), and, if the colon 
is distended with air, this point may be the seat of 
acute pain in chronic inflammations of the same region. 

In perforation of the wall of the stomach or intestine 
there is apt to be a marked increase in the intensity 
of abdominal tympany, and liver and splenic dulness 
may disappear. Liver dulness may also be absent in 
extreme tjTiipanites alone. With this there is rapid, 
weak pulse, and signs of a general peritonitis. 

In obstruction of the gut the signs may develop 
acutely or slowly, according to the nature of the cause, 
whether kinking, intussusception or embolus on the 
one hand, or progressive tumor growth, etc., on the 
other hand. The small, weak, rapid pulse, and absence 
of passage of flatus and feces, together with violent 
peristalsis, distention, and vomiting make the picture 
striking. The rectum and usual sites of hernise should 
be examined. 

The abdomen may be distended from ascites in 
cardiac, renal, or hepatic disease, or in such peritoneal 
inflammations as occur in peritoneal carcinosis and 
tuberculosis. In the latter two conditions there is often 
little or no tenderness of the abdomen, and in each 
condition the exudate may be localized or encap- 
sulated in some one portion of the peritoneal sac. 



366 EXAMINATION OF THE ABDOMEN 

OTHER ORGANS. 

The rectum should always be examined digitally, 
and if necessary instrumental ly. The bladder and 
vagina should be explored if there is any indication of 
interference with their function or structure, and often 
for the sake of determining the position of adjacent 
inflammatory or neoplastic processes. The stomach 
should usually be explored, information at the same 
time being obtained as to the patency and size of the 
esophagus. 



CHAPTER XI. 
ORDER OF PHYSICAL EXAMINATION. 

Order of physical examination — Standard classifications of 
pulmonary tuberculosis. 

For the sake of having a reasonably complete record 
of a physical examination it is imperative that the 
student should become so used to a logical and definite 
order that omissions are unlikely to occur. To this 
end the following scheme or order of physical examina- 
tion is included: 

General Appearance. — Height, weight, nutrition, 
type of physique, active and passive posture. Expres- 
sion. 

Constitutional Signs. — Body temperature. Pulse 
rate. Respiration rate. 

Psychical Conditions. — Intelligence, consciousness, 
restlessness, convulsions, delirium, apathy, stupor, coma, 
speech, memory. 

Skin. — Texture, color (cyanosis, icterus, pigment), 
moisture, temperature, edema, emphysema, hemor- 
rhages, insect bites, eruptions, scars, collateral, venous, 
or capillary circulation, striae, desquamation. 

Head. — Shape and size, symmetry. 

Eyes. — Position, motion, equality and size of pupils, 
reactions of pupils to light and accommodation, acute- 
ness of vision, conjunctivae. 



368 ORDER OF PHYSICAL EXAMINATION 

Ears. — Hearing, mastoid tenderness, tophi, discharge. 

Nose. — Patency of nares or obstructions, odor, 
secretions, perforation of septum. 

Lips. — Color, moisture, eruptions. 

Teeth. — Gums swohen, puffy, pyorrhea, lead line, 
caries, absence, saliva. 

Palate. — Broad, narrow, arched, perforated. 

Pharynx. — Color, exudates, tonsils. 

Neck. — Glands, lymph nodes, thyroid, enlargement 
or pulsations of veins and arteries, thrills, murmurs, 
venous hum. 

Larynx. — ^Tracheal tug, cough, voice. 

Esophagus. — Swallowing. 

Vertebra. — ^Curvature, tenderness, mobility. 

Chest. — ^Variations in breadth or depth, asymmetry 
of form or function. Abnormal impulses. Shape, 
funnel, rachitic, with rosary, and costal groove. 
Scapulae position. Expansion, measurement. Uni- 
lateral or bilateral bulging or retraction of inter- 
spaces. 

Respiration. — ^Rate, type, diaphragm phenomenon, 
retraction of interspaces, Biot's or remittent breathing. 
Cheyne-Stokes or periodic breathing, dyspnea, inspira- 
tory or expiratory, cough, expectoration. 

Palpation. — Fremitus, vocal, bronchial, pleuritic. 

Percussion. — Systematic, of whole chest. Particular 
attention to comparison of apices and determination 
of lung borders in inspiration and expiration. 

Auscultation. — Breath and voice sounds, adventitious 
sounds. 



ORDER OF PHYSICAL EXAMINATION 369 

Heart. — Inspection, apex, location and character 
of beat; presence of abnormal pulsation. 

Palpation. — Site and character of apex beat; site and 
time of thrill; abnormal pulsation; shock of second 
sound.. 

Percussion. — Borders of heart, change on altered 
position. 

Auscultation. — Character of first and second sounds, 
or their component parts at the several valvular areas, 
murmurs, place, time, maximum intensity, direction of 
transmission, character, effect of change of position. 

Pulse. — Size, force, frequency, rhythm, tension 
or blood-pressure (instrumental determination), vessel 
wall, character, symmetry on two sides, delay. 

Abdomen. — Form, circumference, umbilicus, resist- 
ance, percussion, palpation, visible movements, tumors, 
size, consistency, mobility, relation to respiration and 
to other organs, fluctuation, tenderness, auscultation of 
abnormal sounds. 

Liver. — Upper limit, lower border, character of 
surface and edge, smooth, nodular, tender, pulsating. 

Spleen. — ^Area of dulness, edge, character of surface. 

Stomach. — Size, visible movements, splashing, ten- 
derness, tumors, if necessary distention with gas or 
fluid and use of tube to empty. 

Kidneys. — Palpation; bladder, retention, palpation, 
and percussion. 

Extremities. — Joints, movements, size, tenderness, 
musculature, atrophy, hypertrophy, altered tonicity, 
trophic abnormalities. 
24 



370 ORDER OF PHYSICAL EXAMINATION 

Lymph Nodes. — Inguinal, axillary, and epitrochlear. 

Skin. — Color, eruptions. 

Reflexes. — Tendon, joint, skin reflexes, also general 
sensibility, locomotion, and muscular efficiency. 

Special examinations to be made whenever necessary 
to a complete diagnosis. Ophthalmoscopic, laryngo- 
scopic, and rhinoscopic, otoscopic, rectal, vaginal, 
urethral, and cystoscopic, special neurological tests, 
sounding of esophagus and stomach. 

STANDARD CLASSIFICATIONS OF PULMONARY 
TUBERCULOSIS. 

For the sake of accuracy in using terms descriptive 
of the various stages or degrees of severity of pulmo- 
nary tuberculous lesions the student is advised to 
avail himself of the definitions which follow. 

A. Tukban's Classification. 

According to Turban we may define the lesion as of 
three grades: 

By grade I we mean a slight lesion extending at most 
to the volume of one -lobe or two half-lobes. 

By grade II, slight lesion extending farther than I, 
but at most to the volume of two lobes; or a severe 
lesion extending at most to the volume of one lobe. 

By grade III, all lesions which in extent of the parts 
affected exceed II. 

By '' slight lesion" we understand disseminated 



PULMONARY TUBERCULOSIS 371 

centres of disease which manifest themselves physically 
by slight dulness, by harsh, feeble, or bronchovesicular 
breathing, and by rales. 

By ''severe lesion" we mean cases of consolidation 
and excavation such as betray themselves by marked 
dulness, by tympanitic resonance, by very feeble 
bronchovesicular, bronchial or amphoric breathing, 
by rales of various kinds. 

Purely pleuritic dulness, unless marked, is to be left 
out of account; if it is serious, the pleurisy must be 
mentioned under the head of tuberculous complications. 

B. The National Association Classification. 

The National Association for the Study and Pre- 
vention of Tuberculosis has adopted the following 
classification : 

Incipient (Favorable). — Slight initial lesion in the 
form of infiltration limited to the apex or a small part 
of one lobe. No tuberculous complications. Slight or 
no constitutional symptoms (particularly including 
gastric or intestinal disturbances or rapid loss of 
weight). Slight or no elevation of temperature, or 
acceleration of pulse at any time during the twenty- 
four hours, especially after rest. Expectoration usually 
small in amount or absent. Tubercle bacilli may be 
present or absent. 

Moderately Advanced. — No marked impairment 
of function either local or constitutional. Localized 
consolidation, moderate in extent, with little or no evi- 



372 ORDER OF PHYSICAL EXAMINATION 



dence of destruction of tissue, or disseminated fibroid 
deposits. No serious complications. 

Far Advanced. — Marked impairment of function, 
local and constitutional. Localized consolidation 
intense; or disseminated areas of softening; or serious 
complications. 

Miliary Tuberculosis {vide p. 238) . 



INDEX. 



Abdomen, auscultation of, 359 
inspection of, 356 
palpation of, 357 
percussion of, 358 
wall of, 364 
Abscess of lung, 51, 53, 230 
Absence of resonance over soft 

tissues, 26 
Adventitious respiratory sounds 
or rales, 36, 170, 172, 
195, 198 
cavernous, 183 
classification of, 170 
consonating, 37 
crepitant, 38, 51, 180, 

210, 224, 229 
dry bronchial, 37, 178, 

195, 201 
fine bubbUng or subcrep- 

itant, 172, 175, 176 
gurgling, 183 
indeterminate, 188 
laryngeal and tracheal, 

170 
metallic tinkling, 37, 168, 

186, 222 
moist bronchial, 36, 172, 

176, 195, 198 
pitch of, 36, 37, 51 
pleural or friction, 38, 48, 

18J^, 209, 342 
sibilant and sonorous, 

178, 201 
splashing or succussion 
38, 187, 222, 344 



Adventitious respiratory sounds, 
subcrepitant. 172, 175, 
176 
tinkling, metalhc, 168, 

186, 222 
tracheal, 51, 170 

Air in pleural space, 34, 48, 147, 

187, 218 

coin test for, 222 
Amphoric resonance, 102 
conditions causing, 103 

respiration, 33, 144 

voice, 165 

whisper, 165 
Analysis of sounds, 23, 55 
Aneurism, thoracic, 53, 95, 350, 
Aorta and pulmonary artery 

relations of, to chest walls, 

257 
Aortic diastolic non-regurgitant 
murmur, 312, 333 

direct murmur, 308, 317, 
333 

lesions, diagnosis of, 333 

regurgitant murmur, 311, 
333 
Apex beat of heart, modifica- 
tion of, 253, 254, 270, 322, 

326, 338, 340 
Apoplexy, pulmonary, 95, 230 
Artery, pulmonic, and aorta, 

relation of, to walls of chest, 

257 
Asthma, 51, 179, 200 
Atelectasis, lobular, 49, 197 
Atrophy, senile, of lungs, 203, 

206 ■ 



374 



INDEX 



Auscultation, definition of, 41, 
107 
in disease, 130 
in health, 107, 114 
mediate and immediate, 108 
physical basis of, 30 
position for. 111 
rules in practice of, 110 



B 



Blood currents, aortic, 294 
direct, 294, 298 
mitral, 294 
pulmonic, 298 
regurgitant, 295 
relation of, to heart sound, 

295 
tricuspid, 298 
Bony resonance, 25, 83 
Bread, use of, to imitate pul- 
monary signs, 29, 75, 100, 102 
Breath sounds. {See Respira- 
tion.) 
Bronchi, obstruction of, 31, 52, 
354 
relations of, to chest wall, 66, 
67, 69 
Bronchial rales, dry, 37, 178, 
195, 201 
moist, 36, 172, 176, 195, 198 
respiration, 30, 138 

causes, 30, 138 
whisper, increased, 30, 162 
normal, 163 
Bronchitis seated in large bron- 
chial tubes, 51, 19 Jf. 
in small bronchial tubes, 
(capillary), 51, 196 
Bronchocavernous respiration, 

148 
Bronchophony, 155 

whispering, 157, 162 
Bronchorrhagia, 51 
Bronchorrhea, 51, 173 
Bronchovesicular respiration, 

33 140 
Bruit de diable, 309 



Capillary bronchitis, 196 

pulse, 290 
Cardiac, {See Heart.) 

space, superficial and deep, 
78, 205, 252, 256, 324 
Cavernous rale, 183 
respiration, 34, 145 
imitation of, 148 
Cavities, pulmonary, 33, 53, 

213, 248 
Change of pitch, Wintrich's, 27, 

105 
Chest, anatomy and physiology 
of, 43, 251, 258, 304 
regional divisions of, 62, 77, 
117 
Cirrhosis of lung, 248 
Cog-wheel respiration, 153 
Coin sound, 222 
Collapse of lung, 50, 197, 209, 

219 
Conditions, morbid physical, 
incident to different 
diseases of the respi- 
ratory system, 47, 
190 
summary of, 54 
physical, of heart, in disease, 
251, 267 
in health, 252 
represented by amphoric reso- 
nance, 103 
by cracked-metal reso- 
nance, 104 
by dulness, 97 
by flatness on percussion, 

94 
by pulmonary resonance, 

28 
by tympanitic resonance, 

28, 99 
by vesiculotympanitic reso- 
nance, 101 
Congestion, hypostatic, of 

lungs, edema in, 234 
Coughing, signs obtained by, 
168 



INDEX 



375 



Cracked-metal resonance, 104 

imitation of, 104 
Crepitant rale, 38, 51, 180, 210, 
224, 229 



Death rattles, 171 
Diaphragmatic hernia, 249 
Diseases of respiratory system, 

physical conditions incident 

to, 47, 190 
Dulness, 96 

conditions causing, 26, 27, 96 

hepatic, 80, 84 

tympanitic, 99, 247 
Duration of sounds, 59 
Dysphagia in thoracic aneurism, 

354 



E 



Echo, amphoric, 165 

Edema, pulmonary, 51, 97, 182, 

198 233 
Egopliony, 158, 213 
Ellis's line of fluid, 211 
Emphysema, interlobular, 50 

pulmonary or vesicular, 50, 
101, 152, 202, 206 

rhythm of respirations in, 206 
Empyema, 48, 209, 216 

pulsating, 216 
Endocardial murmurs, 294, 297, 

318 
Endocarditis, diagnosis of, 340 
^Exocardial murmur, 294, 319 
Exophthalmic goitre, 345 
Expiratory sound, prolonged, 

151 
Exploration, physical, different 

methods of, 40 
Exudation in air vesicles, 50 



Fissures, interlobar, 45, 62, 63, 
64, 68, 69 



Flatness, 26, 94 

conditions causing, 94 
hepatic, 78, 80, 84 
Flint murmur, 303 
Fluid in chest, 48, 95, 210 
Fremitus, in different regions, 
125 
diminished, 167 
increased, 159, 161 
normal, vocal, 122 
suppressed, 167 
vibration, rate of, 39 
Friction murmur, pericardial, 
294, 318, 342 
pleuritic, 48, 184, 209, 342 
pleuropericardial, 342 



G 



Gangrene, pulmonary, 50, 53, 
232 

Garland's line, 211 

Gerhardt's tone change, 105 

Glottis, edema of, 192 
paralysis of, 192, 354 
spasm of, 191 

Goitre, exophthalmic, 345 

Graham-Steel murmur, 317 

Grocco's sign. {See Paraverte- 
bral Triangle.) 

Gurgling rale, 183 



H 



Heart, abnormal impulses of, 
270 
anatomical relations of, 252, 

258, 304 
angina pectoris, 345 
apex beat of, 253, 270, 322, 

324, 326, 331 
arrhythmias of, 283 
auricular fibrillation in, 283, 

300, 340 
congenital defects of, 348 
patent ductus arteriosus, 
349 



376 



INDEX 



Heart, congenital defects of, 
patent foramen 

ovale, 349 
interventricular sep- 
tum, 349 
pulmonary valve, 315, 

337 
transposition of viscera, 

348 
tricuspid valve, 336 
valvular, 348 
diagnosis of diseases of, 321 
dilatation of, 269 
enlargement of, 267, 328 
extrasystoles of, 286 
first sound of, intensified, 
275 
weakened, 275 
Flint murmur, 304 
functional disorders of, 344 
angina pectoris, 345 
exophthalmic goitre, 345 
irregularities, 283 
palpitation, 346 
hypertrophy of, 269, 322 
and dilatation of, signs of, 
269, 327, 322, 326 
inflammation of, 228 
irregularity of, 283 
mobility of, 253, 324 
murmurs of, 251, 292, 342 

mitral, 292 
muscle, diseases of, 338 

acute myocarditis, 338 
in anemia, 339 
auricular fibrillation, 340 
chronic myocarditis, 

339 
heart-block, 283, 285, 

286, 340 
in infectious diseases, 338 
perpetual irregularity, 
283, 300, 340 
normal, 322 
palpitation of, 346 
physical condition of, in 
disease, 251, 267 
in health, 251 
sounds of, 260, 331, 332 



Heart, sounds of, abnormal 
modifications of, ^7^, 
327, 330, 331, 340, 343 
four in number, 266 
mechanism of, 262, 263 
mitral systolic, 263, 279, 331 
pulmonic, change of, causes 
of, 278 
intensity of, at different 

ages, 265 
weakened, 277 
reduplication of, 279 
second, aortic, weakened, 

276 
third, 261, 297, 332 
tricuspid systolic, 233, 266, 
279 
valvular lesions of, 272, 328 
aortic, 308, 311, 338 
coexisting, 313 
mitral, 299, 303, 305, 329 
pulmonic, 315, 316, 337 
tricuspid, 314, 315, 336 
Hemorrhagic infarcts, 50, 95, 

230 
Hernia, diaphragmatic, 53, 249 
Hum, venous, 309 
Hydatids of lung, 50 
Hydrothorax, 48, 207, 217 
Hydropneumopericardium, 344 
Hydropneumothorax, 38, 220, 
221, 222 



Indeterminate rales, 188 
Infarctus, hemorrhagic, 50, 95, 

230 
Inspiratory sound shortened, 

150 
Intensity of normal and abnor- 
mal sounds, differences of, 19, 
56, 73, 98 
Interrupted respiration, 153 
Interstitial pneumonia, 248 



Jerking respiration, 153 



INDEX 



377 



Kidneys, palpation of, 364 



Laryngeal and tracheal rales, 
170 
respiration, 112 
voice, 121 
Laryngismus stridulus, 191 
Larynx, foreign bodies in, 193 
and trachea, affections of, 191 
edema of, 192 
obstruction of, 192 
tumors of, 192 
ulcers of, 192 
Lesions, valvular, of heart, 272, 
328 
diagnosis of, 328 
Liquid in chest, 48, 95, 210 
Liver, dulness over, 80, 84 
flatness over, 80, 84 
information obtained from 
examination of, 360 
Lobular pneumonia, 50, 197, 

198 
Lobules, pulmonary, collapse of, 

49, 197 
Lung, solidification of, 49, 61, 
139, 156, 159, 226 

M 

Metallic tinkling, 168, 186, 

222 
Mitral lesions, diagnosis of, 329 
murmurs, diastolic, 265 
direct, 299 
Flint, 303 

presystoUc, 299, 303 
regurgitant, 305 
systolic non-regurgitant or 
intraventricular, 305 
Murmur, aortic, direct, 308, 317 
prediastolic, 312 
cardiac, 260, 272, 292, 299, 
319, 339, 341 



Murmur, diastolic or non-re- 
gurgitant, 312 
endocardial, 294, 319 

coexisting, 313 
mitral, causation of, 299, 306, 
329 
diastohc, 295, 331 
direct, 299, 302, 331 
limits of, 305, 306 
mechanism of, 299, 330 
presystoUc, 295, 297, 300 
regurgitant, 297, 329 
systolic, hemic, functional, 
and cardiorespiratory, 
305, 329 
thrill with, 302, 316, 334 
without mitral lesions, 302, 
303, 305, 329, 339 
normal, vesicular, 114 

in different regions, 117 
pericardial or friction, 294, 

318, 342 
pulmonic, direct, 315 

regurgitant (Graham- 
Steell), 316 
regurgitant, 295, 305, 311, 

315, 316 
tricuspid, direct, 314, 337 

regurgitant, 315 
vesicular, causes, 32 
diminished, 133 
increased, 132 
suppressed, 136 
Murmurs, endocardial, 292, 294, 
319 
exocardial, 294, 319 
facts of importance relating 

to, 317 
hemic, 293 

organic and inorganic, 292 
Myocarditis, 338 



N 



National association classifi- 
cation of pulmonary tubercu- 
losis, 371 

Neoplasms of lung, 50, 52, 235 



378 



INDEX 



O 



Order of physical examination, 

367 
Organs, respiratory, anatomy 

and physiology of, 43 
Overtones, 21 



Palpitation, cardiac, 275, 
343 

Paravertebral triangle in pleu- 
risy, 211 

Pectoriloquy, 163 

Percussion, analysis of sounds 
in, 23, 55 
definition of, 41 
in disease, 93 
in health, 71 
instruments for, 71 
modes of performing, 72 .88 
objects of, 73 
position for, 89, 90, 91 
rules in practice of, 89 
sense of resistance in, 105 
signs of disease furnished by, 
93 

Pericardial or friction murmur, 
294, 318, 342 
sac, liquid within, 273, 343 
surfaces, roughness of, 273, 
342 

Pericarditis, chronic, 343 
diagnosis of, 342 

Phonendoscope, 109 

Phthisis, 50, 51, 239, 370 
advanced, 2U, 248, 370 
classification of, 370 
differential diagnosis of, 245 
fibroid, 248 

groups of cases in, 240, 370 
incipient, 240, 2J^3, 244, 370 
moderate, 240, 370 
signs, direct and accessory of, 
241 

Physical examination, order of, 
367 



Pitch of normal and abnormal 
sounds, 20, 27, 56, 57, 74 
Wintrich's, change of, 27, 105 
Pleural rales, 48, 184, 2O0, 342 
Pleurisy, acute and chronic, 48, 
61, 207, 209 
chronic, signs of, 214, 215 
diaphragmatic, 209 
dry fibrinous, 209 
exceptional signs of, 217 
first stage of, friction sound 
in, 209 
signs of, 209 
mediastinal, 209 
paravertebral triangle of dul- 

ness in, 211 
second stage of, horizontal 
and S-shaped lines in, 
211 
signs of, 210 
with effusion, 210 
Pleuropericardial murmur, 342 
Pleuropneumonia, 223 
Pneumohydropericardium, 344 
Pneumohydrothorax, 38, 220, 
221, 222 
amphoric voice in, 222 
coin sound in, 222 
metallic tinkle in, 222 
succussion splash in, 222 
Pneumonia, acute lobar, 49, 223 
circumscribed, 230 
crepitant rale in, 224, 229 
embolic, 50, 231 
interstitial, 50, 248 
lobular, 50, 197, 198, 230 
massive, 31 

signs of abscess in, 230 
in first stage, 224 
of purulent infiltration 

in, 230 
in second stage, 227 
in third stage, 228 
Pneumopyothorax, 218 
Pneumorrhagia, 51, 232 
Pneumothorax, 34, 48, 147, 187, 
218 
coin test for, 222 
Precordia, 252, 267 



INDEX 



379 



Pulmonary apoplexy, 182, 230 

edema, 51, 95, 182, 233 

gangrene, 50, 232 
Pulmonic direct murmur, 315 

lesions, diagnosis of, 315, 316, 
337 

regurgitant murmur, 316, 337 
Pulse, arterial, 281 

capillary, 290 

character of vessel wall, 290 

frequency of, 282 

inequality of radial, etc., 354 

irregularities of, 283 

rapidity of, 289 

regularity of, 283 

size of, 288 

tension of, 289 

venous, 284, 291 
Pupils, inequality of, in thoracic 

aneurism, 354 
Pyopneumothorax, 38, 220, 221, 

222 
Pyothorax (empyema), 48, 209, 
'216 



Quality of normal and abnor- 
mal sounds, 20, 57, 74 
terms denoting, 59 



R 



Rales, 170 

cavernous or gurgling, 183 
classification of, 133, 170 
consonating, 37 
crepitant or vesicular, 38, 51, 

180, 210, 224, 229 
dry bronchial, 37, 178, 195, 

201 
fine bubbling or subcrepitant, 

171, 175, 176 
gurgling, 183 
indeterminate, 188 
laryngeal and tracheal, 170 
metallic tinkling, 37, 168, 186, 

222 



Rales, moist bronchial, 36, 172, 
176, 195, 198 
pitch of, 36, 37, 51 
pleural or friction, 48, 184, 

209, 342 
sibilant and sonorous, 178, 281 
splashing or succussion, 187, 

222, 344 
subcrepitant or fine bubbling, 

172, 175, 176 
tinkling, metalhc, 37, 168, 186 

222 
tracheal, 51, 170 
vesicular or crepitant, 51, 
180, 210, 224, 229 
Regions, anatomical relation of, 
66 ff. 
divisions of chest into, 62 
Resistance, sense of, in percus- 
sion, 105 
Resonance, absence of, or flat- 
ness, 26, 94 
amphoric, 102 
bone, osseous resonance over, 

25, 83 
cracked-metal, 104 
in different regions, 76 ff . 
diminished, or dulness, 26, 27, 

96 
disparity of, on the two sides, 

85 
normal, vesicular, on percus- 
sion, 74 
vocal, over larynx and 
trachea, 121 
over chest, 122 
standard for, 85 
tympanitic, 76, 82, 98 
variations in different regions 

of chest, 76 
vesiculotympanitic, 101, 204 
vocal, diminished, 165 
increased, 159 
causes of, 159 
Resonators, sounds intensified 

by, 22 
Respiration, abnormal modifi- 
cations of, 131 
amphoric, 144 



380 



INDEX 



Respiration, amphoric, imita- 
tion of, 145 
bronchial or tubular, 138 
bronchocavernous, 148 
broncho vesicular, 140 
cavernous, 145 
in different regions, 117 
diminished, 133, 193, 198, 205 
harsh, 140 
indeterminate, 141 
interrupted, 153 
normal, laryngeal, and tra- 
cheal, 112 
vesicular murmur of, 114 
puerile, 132 
rude, 140 

supplementary, 132 
suppressed, 136 
vesicular murmur of, in- 
creased, 132 
vesiculocavernous, 149 
Respiratory organs, anatomy, 
physiology of, 43 
physical conditions inci- 
dent to diseases of, 47, 
54, 190 
Rhythm, respiratory, in emphy- 
sema, 206 



S-SHAPED line of fluid, 211 
Sense of resistance, 105, 106 
Serofibrinous pleurisy, 210 
Significance of morbid signs, 61 
Signs (distinguished from symp- 
toms), 41 
healthy and morbid, distinc- 
tive characters of, 41, 55 
object of, 42 

obtained by coughing, 168 
by percussion, in disease, 93 
in health, 71 
physical definition of, 41 
respiratory, classification of, 
131 
in disease, 130 ff. 
in health, 107 ff. 



Signs, significance of, 60 

as representing physical 
conditions, 61 
vocal, in health, 121 
of disease, 155 
Sounds. {See also. Heart 
Sounds and Respiratory, 
56.) 
analysis of, 23 

differences of intensity in, 56 
in pitch, 20, 56 
in quality, 20, 56 
dispersion of, 24, 31 
intensification of, 22 
normal and abnormal, 18, 110 
overtones in, 21 
transmission of, 18, 24 
velocity of, 18 
vibration rate of, 18 
Splashing or succussion sounds, 

38, 187, 222, 344 
Spleen, 81, 362 
Standard of normal resonance, 

75, 88 
Stethoscope, 23, 109 
Stomach, 82, 359 
Succussion or splashing sounds, 
38, 187, 222, 344 



Third heart sound, 261, 297, 332 

Thoracic aneurism, 350 

diagnosis of, from empy- 
ema, 308 

Thrill, with mitral stenosis mur- 
murs, 302 
with aortic stenosis, 334 
with pulmonic stenosis, 316 
with thoracic aneurism, 352 

Tinkling, metalhc, 168, 186, 222 

Tone, Williams's tracheal, 105 

Tones, 19 

Trachea, affections of, 191 

Tracheal respiration, 112 

Traube's space, 82 

Tricuspid, direct murmur, 314, 
337 



INDEX 



381 



Tricuspid lesions, diagnosis of, 
293, 336 
regurgitant murmur, 314, 337 
safety-valve function of, 298 

Tuberculosis, acute, 198, 238 
classification of, 370 
miliary, 238 

Tubular respiration, 138 

Tumor within chest, 53, 95, 235, 
344 

Turban's classification of pul- 
monary tuberculosis, 370 

Tussive signs, 168 

significance of, 169 

Tympanitic resonance, 98 

conditions causing, 27, 99 

Tympany, dull, 27, 99, 247 

, over-relaxed lung, 28 



Valvular cardiac lesions, 272, 
328 
aortic, 308, 311, 333 
mitral, 262, 267, 329 
pulmonic, 315, 316, 337 
tricuspid, 314, 315, 336 
Venous hum, 309 

pulse, 291 
Vesicular rale, 180 
resonance, normal, 73 



Vesiculocavernous respiration, 

149 
Vesiculotympanitic resonance, 
101, 204 
conditions causing, 101 
Vocal fremitus, diminished or 
suppressed, 167 
increased, 159 
normal, 122 
resonance, diminished and 
suppressed, 165 
in different regions, 124 
increased, 159 
normal, 121 
signs of disease, 155 
Voice, abnormal, 155 
amphoric, 165 
laryngeal and tracheal, 126 
normal, 122 



W 

Wavy respiration, 153, 243 
Whisper, amphoric, 165 

bronchial, increased, 162 

cavernous, 163 

in different regions, 127 

normal, 127 
Whispering pectoriloquy, 164 
Williams's tracheal tone, 105 
Wintrich's change of pitch, 27, 

105 



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